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SWALLOW-INDUCED TRANSIENT SPATIAL SEPARATION OF CRURAL DIAPHRAGM AND LOWER ESOPHAGEAL SPHINCTER IS ASSOCIATED WITH GASTROESOPHAGEAL REFLUX
Takahiro Masuda*1,2, Saurabh Singhal1,2, Shunsuke Akimoto3, Sumeet Mittal1,2
1Thoracic and Esophageal Surgery, Norton Thoracic Institute, Dignity Health, Phoenix, AZ; 2Surgery, Creighton University School of Medicine, Omaha, NE; 3Surgery, The Jikei University School of Medicine, Tokyo, Japan
INTRODUCTION: A subset of patients with manometrically normal lower esophageal sphincter has pathological distal esophageal acid exposure. The aim of this study is to assess the association of gastro-esophageal reflux with swallow-induced transient hiatal hernia secondary to esophageal body shortening (EBS) in these patients.
METHODS AND PROCEDURES: After IRB approval, we queried prospectively maintained database to identify patients who underwent pH study and high-resolution manometry (HRM) between Jan. to Dec. 2015. Patients with Type I EGJ morphology (no hiatal hernia) based on Chicago Classification v 3.0 were included in this study. EBS was measured as distance between Lower esophageal sphincter (LES) and Crural diaphragm (CD) with swallow-induced esophageal body contraction. Number of episodes of EBS of ≥1 cm was counted for 10 swallows. Patients were divided into 2 groups: 1. EBS positive group (EBS present in ≥3 swallows), 2. EBS negative group (EBS present in ≤2 swallows). Maximum length of EBS was also measured.
RESULTS: A total of 90 patients underwent HRM and pH study during the study period. 41 patients had Chicago EGJ-Type I. Mean age was 47.2 years with 35 females and a BMI of 33.9. Median number of EBS ≥1 cm was 1. Sixteen patients were categorized as EBS positive group (≥3 EBS of ≥1 cm). EBS positive group had higher rate of abnormal DeMeester score than negative group (56% vs 28%), however, this did not reach statistical significance (p=0.070). There were 17 patients who had maximal EBS ≥2 cm and were more likely to have pathological reflux than patients with maximal EBS <2 cm group (59% vs 25%, p=0.029).
CONCLUSIONS: Esophageal body shortening of ≥2 cm in patients with Chicago EGJ-Type I have a higher prevalence of pathological reflux disease. The degree of swallow-induced hiatal hernia could be an early indicator of lower esophageal sphincter dysfunction. Further studies are needed to confirm these findings.
Table
| | EBS<2 cm | EBS ≥2 cm | p-value | | N=24 | N=17 | | Age (years) | 42 (35-49) | 52 (40-62) | 0.043 | | Sex (M:F) | 3:21 | 3:14 | 0.488 | | BMI (kg/m2) | 33.6 (28.9-40.4) | 34 (25-41.5) | 0.427 | Chicago
classification
ver3 | Normal | 58.3% (14/24) | 58.8% (10/17) | 0.975 | | EGJOO | 33.3% (8/24) | 41.2% (7/17) | 0.607 | | IEM | 8.3% (2/24) | 0% (0/17) | 0.337 | | Percent pH<4 holding time (%) | 1.55 (0.25-3.4) | 5.2 (1.5-8.5) | 0.046 | | DeMeester Score | 6.8 (2.35-13.25) | 16.8 (6.4-33.7) | 0.055 | | DeMeester Score>14.72 | 25% (6/24) | 58.8% (10/17) | 0.029 |
M:F = male:female; EGJOO = EGJ outflow obstruction; IEM = Ineffective esophageal motility. Values are reported as median (IQR).
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