Characterization and follow‐up of esophagogastric junction outflow obstruction detected by high resolution manometry

Pérez-Fernández, María Teresa; Santander, Cecilio; Marinero, Almudena; Burgos‐Santamaría, Diego; Chavarría, Carlos

doi:10.1111/nmo.12708

Cited by 125 publications

(164 citation statements)

References 44 publications

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“…Similar findings are found also in patients with dysphagia after restrictive, antireflux and bariatric procedures [45][46][47] . However, two series published in the past few years found that many patients with EGJOO were minimally symptomatic or asymptomatic, that in 20-40% of cases the 'disorder' resolved spontaneously, and that only 12-40% were treated (conservatively) as having achalasia 48,49 .…”

Section: Achalasia With Preserved Peristalsismentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

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Section: Achalasia With Preserved Peristalsismentioning

confidence: 99%

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Kahrilas

Bredenoord

Fox

et al. 2017

Nat Rev Gastroenterol Hepatol

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“…This characterization was based on a large cohort of patients undergoing HRM in which 34 out of 1,142 patients were diagnosed with primary EGJ outflow obstruction. Additional research has suggested that if patients with EGJ outflow obstruction present with dysphagia or chest pain as the main symptoms, the patient may need specific treatment and that endoscopic and surgical approaches are more effective than pharmacological treatment (6). This finding was based on a retrospective and prospective study of a historical cohort and a healthy control group that included 28 patients diagnosed with EGJ outflow obstruction receiving different therapeutic treatments including therapeutic abstention, pharmacological, botulinum toxin in the lower esophageal sphincter, endoscopic dilation, and surgery (fundoplication reversal).…”

Section: Discussionmentioning

confidence: 99%

Esophagogastric junction outflow obstruction-related functional chest pain treated using robotic-assisted thoracoscopic esophageal myotomy

Lin

Huang

2017

J. Thorac. Dis.

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Elevated relaxation pressure in combination with intact or weak peristalsis characterizes esophagogastric junction (EGJ) outflow obstruction. Symptoms of EGJ outflow obstruction include dysphagia and atypical chest pain. EGJ outflow obstruction can be diagnosed using high-resolution manometry (HRM), but there is a lack of consensus regarding treatment. We present a case report of a 43-year-old man with a history of headache and mitral valve disorder who suffered from intermittent atypical chest pain for 20 years. A diagnosis of EGJ outflow obstruction was made using esophageal HRM.Due to medication intolerance, robotic-assisted esophageal myotomy and Belsey-Mark IV fundoplication were performed. The symptoms went into complete remission and no motility disorders were detected on postoperative HRM. HRM is a useful diagnostic examination for EGJ outflow obstruction. The robotic systems-assisted long segment myotomy may potentially play an important role in the treatment of EGJ outflow obstruction-related functional chest pain. J Thorac Dis 2017;9(5):E432-E436 jtd.amegroups.com of a cardiovascular disorder. He visited a local GI clinic where panendoscopy revealed gastroesophageal reflux. The Eckardt score was 9. The pain was poorly controlled with symptoms worsening despite more than 5 years of treatment with proton-pump inhibitors and hyoscine-N-butylbromide under the guidance of the local clinic.The patient underwent HRM and esophagraphy at the Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan and there was no acid reflux and chest pain during the examination. The esophagraphy reveal peristalsis passes normally through the entire esophagus ( Figure 1A). The Chicago Calculation data for swallows (liquid) revealed an abnormal IRP. The median IRP was 15 mmHg (Figure 2A). The distal latency in 5 out of 10 swallows (5 mL each) was normal (>4.5 s), and for 6 out of 10 swallows, the contractile front velocity was normal (<9 cm/s). In addition, the median and maximum distal contractile integrals were 1,445 mmHg/s/cm (<5,000 mmHg/s/cm) and 2,725 mmHg/s/cm (<8,000 mmHg/s/cm), respectively. The amplitude of proximal esophagus (25.0 cm) was 49 mmHg; The amplitude of middle esophagus (30 and 35 cm) were 104 and 119 mmHg, respectively; The amplitude of distal esophagus (40 cm) was 102 mmHg. The HRM finds with elevated median IRP (>15 mmHg) and normal distal latency. The esophagraphy reveal peristalsis passes normally through the entire esophagus. The patient was diagnosed as having EGJ outflow obstruction based on the Chicago Classification of esophageal motility disorders, v3.0 (4). However, the chest pain was not provoked during the HRM, thus the possibility of diffuse esophageal spasm (DES) was considered. We tried a calcium channel blocker and nitrite for pain control. The chest pain improved, but a side effect of severe headache occurred. After discussion, Because of worsening symptoms, the patient decided to undergo surgery and refused any additional attempt at endoscopic treatment.R...

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“…Only the 3 patients treated with LHM responded well. 16 Interestingly, Pérez-Fernández et al 17 reported…”

Section: Esophagogastric Junction Outflow Obstructionmentioning

confidence: 99%

Understanding the Chicago Classification: From Tracings to Patients

Schlottmann

Herbella

Patti

2017

J Neurogastroenterol Motil

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Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other new parameters and disorders is still under investigation. (J Neurogastroenterol Motil 2017;23:487-494)

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Characterization and follow‐up of esophagogastric junction outflow obstruction detected by high resolution manometry

Cited by 125 publications

References 44 publications

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Esophagogastric junction outflow obstruction-related functional chest pain treated using robotic-assisted thoracoscopic esophageal myotomy

Understanding the Chicago Classification: From Tracings to Patients

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