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PubMed2005

Gastric banding interferes with esophageal motility and gastroesophageal reflux.

BACKGROUND: Gastroesophageal reflux and progressive esophageal dilatation can develop after gastric banding (GB). HYPOTHESIS: Gastric banding may interfere with esophageal motility, enhance reflux, or promote esophageal dilatation. DESIGN: Before-after trial in patients undergoing GB. SETTING: University teaching hospital. PATIENTS AND METHODS: Between January 1999 and August 2002, 43 patients undergoing laparoscopic GB for morbid obesity underwent upper gastrointestinal endoscopy, 24-hour pH monitoring, and stationary esophageal manometry before GB and between 6 and 18 months postoperatively. MAIN OUTCOME MEASURES: Reflux symptoms, endoscopic esophagitis, pressures measured at manometry, esophageal acid exposure. RESULTS: There was no difference in the prevalence of reflux symptoms or esophagitis before and after GB. The lower esophageal sphincter was unaffected by surgery, but contractions in the lower esophagus weakened after GB, in correlation with preoperative values. There was a trend toward more postoperative nonspecific motility disorders. Esophageal acid exposure tended to decrease after GB, with fewer reflux episodes. A few patients developed massive postoperative reflux. There was no clear correlation between preoperative testing and postoperative esophageal acid exposure, although patients with abnormal preoperative acid exposure tended to maintain high values after GB. CONCLUSIONS: Postoperative esophageal dysmotility and gastroesophageal reflux are not uncommon after GB. Preoperative testing should be done routinely. Low amplitude of contraction in the lower esophagus and increased esophageal acid exposure should be regarded as contraindications to GB. Patients with such findings should be offered an alternative procedure, such as Roux-en-Y gastric bypass.

Adult↗
PubMed1979

Effective surgical therapy of esophagitis. Experience with Belsey, Hill, and Nissen operations.

During the years 1971 to 1978, 252 patients needed surgical treatment of primary or secondary esophagitis. Major operations performed were 73 Belsey Mark IV repairs, 55 Hill repairs, and 129 Nissen repairs. In the group with primary reflux, barium swallow tests and endoscopy were useful in confirming the diagnosis in patients with typical symptoms; routine biopsy, lower esophageal sphincter, manometry or an acid infusion test did not add to diagnostic certitude. If symptoms were atypical, a biopsy was helpful but manometry and acid infusion were not. Mean symptom scores in this group of patients were improved by each of the "valve-building" operations. Intraoperative dilation after mobilization of the esophagus coupled with a valve-building operation was successful in managing 26 of 29 strictures. Reoperation after an operation failed carried appreciable morbidity and mortality but resulted in good control of symptoms. Addition of a Belsey or Nissen procedure to myotomy for management of primary esophageal motility disorders diminished symptoms and did not cause disabling obstruction.

Collagen Diseases↗
PubMed2001

Esophageal involvement and pulmonary manifestations in systemic sclerosis.

OBJECTIVE: To assess whether esophageal manometric motor disturbances are associated with abnormalities consistent with interstitial lung disease (ILD) on both pulmonary function tests (PFT) and high resolution computerized tomography (HRCT) scans in patients with systemic sclerosis (SSc), during initial evaluation and at 2 years followup. METHODS: Esophageal manometry, PFT, and HRCT scans were performed in 43 consecutive SSc patients. PFT and HRCT scan parameters were compared between patients with severe esophageal motor dysfunction (i.e., aperistalsis and decreased low esophageal sphincter pressure), patients with moderate esophageal motor dysfunction (hypoperistalsis), and patients without esophageal motor dysfunction on manometry. RESULTS: During initial evaluation of SSc, patients with severe esophageal motor impairment, compared with those with moderate and without esophageal dysmotility, exhibited significantly decreased median values of diffusing capacity for carbon monoxide (DLco) (68% vs. 94% vs. 104%) and exhibited higher prevalence of evidence for ILD on HRCT scan (57% vs. 27% vs. 18%). At 2 years followup of SSc, patients with severe esophageal motor disturbances, compared with those without, had faster deterioration of DLco median values (-16% vs. +1%) and higher frequency of ILD on HRCT scan (70% vs. 25%). CONCLUSION: Our series underscores a correlation between the degree of esophageal manometric motor disturbances and evidence for ILD on PFT and HRCT scan in SSc patients, suggesting that gastroesophageal reflux (GER) may be one of the contributing factors of ILD in SSc. Our findings further indicate that patients with severe esophageal impairment may require closer followup of lung parameters. In turn, it suggests that aggressive therapy of GER should be initiated in these SSc patients, as it may result in decreased deterioration of pulmonary function.

Adult↗
PubMed1987

Clinical implications of abnormal oesophageal motility.

The usefulness of oesophageal manometry as a clinical tool has been assessed in 202 patients requiring detailed investigation for troublesome oesophageal symptoms, who first presented between June 1979 and May 1982. Only 12 were found to have specific motility disorders such as achalasia and scleroderma. A total of 147 had a variety of non-specific motility disorders and, of these, 112 (76.2 per cent) had coexistent gastro-oesophageal reflux. There was a significant association between the symptoms of dysphagia and the occurrence of predominantly non-propagated motor activity in the oesophagus. A similarly significant relationship existed between crushing chest pain and oesophageal spasm. Despite this statistical association, detection and treatment of gastro-oesophageal reflux was found to be the most useful part of clinical management. Symptoms of associated motility disorders resolved in more than 90 per cent of patients treated by Nissen fundoplication. Preoperative assessment of motility was of no value in detecting those who might develop postoperative dysphagia. Oesophageal manometry is useful for the assessment of a small proportion of patients with oesophageal symptoms in whom gastro-oesophageal reflux has been excluded by vigorous investigation, including 24 h pH recording.

Deglutition Disorders↗
PubMed1989

Effect of anterior resection on anal sphincter function.

Minor difficulties with continence may occur after low anterior resection. Intraoperative injury to the internal anal sphincter or its nerve supply may contribute to this. To study the effect of low anterior resection on the anal sphincter mechanism, anal manometry was performed on 20 patients before and 10 days after resection. Fifteen patients were studied again 6 months after operation. Resting, maximum squeeze and squeeze increment pressures were recorded. Intraoperative manometry (n = 11) and presacral nerve stimulation (n = 6) were performed to determine whether peroperative injury to the internal anal sphincter had occurred. Resting and maximum squeeze anal canal pressures were reduced by low anterior resection, and did not recover. The squeeze pressure increment did not change. Division of the inferior mesenteric artery, full mobilization of the rectum and mesorectum, and rectal transection did not affect resting anal pressure, which was reduced after EEA anastomosis (mean (s.e.m.) before, 40(5) mmHg; after, 27(4) mmHg; P less than 0.05, n = 5). Presacral nerve stimulation produced relaxation of the internal sphincter. Anal sphincter pressures are reduced after low anterior resection. The external anal sphincter and the nerve supply to the internal anal sphincter appear intact. A direct injury to the internal sphincter is postulated.

Adult↗
PubMed1995

Pelvic floor physiology in women with faecal incontinence and urinary symptoms.

Anorectal manometry, balloon proctometrography, measurement of anorectal angles and videourodynamics were used to investigate 45 asymptomatic women and 13 with faecal incontinence and urinary symptoms, nine of whom also had stress urinary incontinence. The anorectal angle was measured and videourodynamics performed on 17 constipated women with urinary symptoms. Mean (s.e.m.) values obtained with anorectal manometry were lower in women with faecal incontinence and urinary symptoms than in controls (maximum resting pressure 42.5(8.1) versus 82.5(9.3) cmH2O, P = 0.001; maximum attained pressure 80.5(13.7) versus 216.2(11.2) cmH2O, P = 0.001; maximum squeeze increment 35.3(7.5) versus 141.6(10.0) cmH2O, P = 0.001), indicating a weakened puborectalis and external anal sphincter. Mean(s.e.m.) anorectal angles at rest, squeeze and strain were all significantly greater in the doubly incontinent women than in those with constipation (114(3.8) versus 93(5.9) degrees, P = 0.01; 103(2.5) versus 78(3.5) degrees, P < 0.001; 120(2.9) versus 104(4.2) degrees, P = 0.01). Urinary incontinence was worse in the doubly incontinent than in the constipated women (eight of nine versus one of eight with grade 2a or higher, P = 0.002). These results suggest that doubly incontinent women have a significantly weakened pelvic floor and that this should be taken into account before any planned surgery for urinary incontinence.

Adult↗
PubMed1996

Nitric oxide and the rectoanal inhibitory reflex: retrograde neuronal tracing reveals a descending nitrergic rectoanal pathway in a guinea-pig model.

Nitric oxide has been implicated as the neurotransmitter mediating internal anal sphincter (IAS) relaxation during the rectoanal inhibitory reflex. However, there has been no direct demonstration of a nitrergic rectoanal neuronal pathway appropriate to mediating the reflex. This study combined retrograde neuronal tracing techniques with enzyme histochemistry in a guinea-pig model. Wheatgerm agglutinin conjugated to horseradish peroxidase was injected into the IAS. Transported tracer was demonstrated in neurones of the myenteric ganglia of the distal rectum and all labelled neurones showed co-localization with nitric oxide synthase as revealed by reduced nicotinamide adenine dinucleotide phosphate diaphorase histochemistry. In vivo anal canal manometry showed that the mean maximal resting pressure was 16 (8-20) cmH2O and confirmed the presence of the rectoanal inhibitory reflex. In vitro organ bath studies showed that strips of IAS developed spontaneous myogenic tone and relaxed in response to intrinsic nerve stimulation. Addition of N omega-nitro-L-arginine (L-NOArg) reduced the relaxant response in a dose-dependent fashion; the relaxant response was maximally reduced by a mean(s.e.m.) 35.2(3.8) per cent (P < 0.001) at a concentration of 3 x 10(-5) mol/l L-NOArg. This study provides direct anatomical evidence of a descending nitrergic rectoanal neuronal pathway in a guinea-pig model. In vivo anal manometry and in vitro organ bath studies provide additional evidence that this pathway is responsible for the inhibitory motor innervation of the rectoanal inhibitory reflex.

Anal Canal↗
PubMedDate not supplied

Manofluorography of deglutition after supraglottic laryngectomy.

Manofluorography (mano: manometry, fluoro: videofluoroscopy, graphy: picture) provides a simultaneous display of manometry and fluoroscopy on one video screen. This study uses manofluorography to analyze the swallowing patterns of nine patients who had undergone supraglottic laryngectomy. The results show that during swallowing the pharyngeal mechanism for preventing aspiration depends upon three processes: (1) tight lingual-laryngeal contact, (2) coordination of the swallowing reflex, and (3) tongue base and pharyngeal constrictor clearing of the hypopharynx and laryngeal inlet. Anterior suspension of the larynx under the tongue base serves to improve lingual-laryngeal contact. This close contact during deglutition protects the airway from the bolus and also opens the postcricoid region, aiding bolus passage into the esophagus. Impairment of the swallowing reflex, which can cause severe aspiration before the swallowing reflex is triggered, can be rehabilitated by swallowing therapy. Minor aspiration is commonly caused by impaired clearing of the superior hypopharynx after supraglottic laryngectomy.

Deglutition Disorders↗
PubMedDate not supplied

Frequency of papillary dysfunction among cholecystectomized patients.

Four hundred and fifty-four consecutive patients who had had their gallbladder removed were interviewed to determine the presence of upper abdominal pain, increased serum alkaline phosphatase and/or serum amylase activity. Patients with unexplained upper abdominal pain and/or enzyme abnormalities were offered endoscopic retrograde cholangiopancreatography (ERCP) and manometric evaluations. Dysfunction of the sphincter of Oddi diagnosed by ERCP manometry may account for the abdominal pain seen in 14% of the patients with postcholecystectomy syndrome. It may rarely be the cause of an elevated serum alkaline phosphatase and/or amylase when abdominal pain is not present. Papillary dysfunction is seen in less than 1% of the patients who have had their gallbladders removed. ERCP manometry is recommended in cholecystectomized patients with unexplained abdominal pain suggesting pancreaticobiliary origin.

Aged↗
PubMed1994

Analysis of intrabolus forces in patients with Zenker's diverticulum.

This report presents 10 patients with Zenker's diverticulum who were evaluated with simultaneous solid-state manometry and fluoroscopy. With this method, intrabolus forces are determined. Each patient had abnormal intrabolus forces regardless of the size of the diverticulum and cricopharyngeal muscle dysfunction. In the literature, there has been conflicting manometry results when studying Zenker's diverticulum. The use of analysis of intrabolus forces increases the sensitivity of manometric evaluation. This study establishes pressure abnormality in the pharyngoesophageal segment of patients with Zenker's diverticulum. The pathogenesis of Zenker's is presented based on these findings.

Deglutition↗
PubMed2005

The vaginal pressure profile.

AIMS: To describe the vaginal pressure profile in asymptomatic nulliparous women. METHODS: Fourteen nulliparous women without symptoms of anal or urinary incontinence were studied with vaginal manometry. A rapid pull-through technique utilized a four-channel water-perfused catheter on a motor-driven puller to create a pressure profile for each subject. The profiles were measured with the subject at rest and during a sustained contraction of the levator ani muscle. The individual subject's pressure profiles were averaged to create a composite profile at rest and during squeeze. RESULTS: The vaginal pressure profile at rest and during squeeze contains three pressure zones: proximal, mid, and distal. The pressure is highest in the mid pressure zone and was labeled as the vaginal high-pressure zone. In the vaginal high-pressure zone, the maximum pressure during squeeze is significantly higher than the maximum pressure at rest (P < 0.05). The length of the high-pressure zone is longer during squeeze as compared to rest (P < 0.05). The maximum pressures exhibit circumferential asymmetry with the pressures in anterior and posterior directions being significantly higher than those in the lateral directions (P < 0.05). CONCLUSIONS: The vaginal pressure profile is more complex than previously described. Understanding of the vaginal pressure profile is crucial when employing vaginal manometry to assess pelvic floor muscle strength or as a surrogate for intra-abdominal pressure.

Adult↗
PubMed2006

Reliability of pelvic floor muscle strength assessment using different test positions and tools.

AIMS: The aims of this study were to determine the intra-therapist reliability for digital muscle testing and vaginal manometry on maximum voluntary contraction strength and endurance. In addition, we assessed how reliability varied with different tools and different testing positions. METHODS: Subjects included 20 female physiotherapists. The modified Oxford scale was used for the digital muscle testing, and the Peritron perineometer was used for the vaginal resting pressure and vaginal squeeze pressure assessments. Strength and endurance testing were performed. The highest of the maximum voluntary contraction scores was used in strength analysis, and a fatigue index value was calculated from the endurance repetitions. Bent-knee lying, supine, sitting, and standing positions were used. The time interval for between-session reliability was 2-6 weeks. RESULTS: Kappa values for the between-session reliability of digital muscle testing were 0.69, 0.69, 0.86, and 0.79 for the four test positions, respectively. Intra-class correlation coefficient (ICC) values for squeeze pressure readings for the four positions were 0.95, 0.91, 0.96, and 0.92 for maximum voluntary contraction, and 0.05, 0.42, 0.13, and 0.35 for endurance testing. ICC values for resting pressure were 0.74, 0.77, 0.47, and 0.29. CONCLUSIONS: Reliability of digital muscle testing was very good in sitting and good in the other three positions. vaginal resting pressure demonstrated very good reliability in all four positions for maximum voluntary contraction, but was unreliable for endurance testing. Vaginal resting pressure was not reliable in upright positions. Both measurement tools are reliable in certain positions, with manometry demonstrating higher reliability coefficients.

Adult↗
PubMed1989

Management of defecation in spina bifida.

The main presenting complaint in defecational disorders in spina bifida is constipation. The principal cause of this complaint is hypofunction or paralysis of muscles in the pelvic floor as a result of the spinal cord injuries. To evaluate the present status of defecation, anorectal manometry with special reference to the anorectal pressure profile has been useful. The possibility of using anorectal manometry for the research of anorectal movement and participation of spinal cord was discussed.

Anal Canal↗
PubMed1989

Anorectal motility in children with complete rectal prolapse.

Anorectal manometry, defecography, and ultrasonographic study were performed in 36 children with complete rectal prolapse and 45 age- and sex-matched controls. Anorectal manometry disclosed that there was no significant difference in Pr, Pac, or length of HPZ between patients and controls. The rate of BRC of the smooth muscle of the anal canal and RC were significantly lower in patients. Rectoanal reflex was present in all patients and controls. Defecography and ultrasonographic examination confirmed the hypothesis that rectal prolapse starts initially as an intussusception of the rectum, then fully develops. In 29 cases patients were cured by conservative treatment, but seven patients required surgical treatment. Results of modified Sudeck's operation were, in general, satisfactory.

Adolescent↗
PubMed1996

Laparoscopic rectopexy for complete rectal prolapse. Clinical outcome and anorectal function tests.

BACKGROUND: The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations. METHODS: Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography. RESULTS: No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p = 0.005) and the rectoanal inhibitory reflex improved in seven patients (p = 0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p = 0.02). CONCLUSIONS: Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.

Aged↗
PubMed1992

Defecatory disorders, anorectal and pelvic floor dysfunction: a polygamy? Radiologic and manometric studies in 41 patients.

A consecutive series of 41 patients with defecatory disorders was prospectively studied by anal manometry and evacuation proctography to determine the relationship between abnormalities and symptoms. The patients (29 female, 12 male, aged 41 +/- 2.3 years) all complained of difficulty in evacuation. All had normal colonoscopy and biochemistry. There was no evidence of megacolon or megarectum, and no symptoms had been previously treated by pelvic floor surgery. All subjects completed detailed questionnaires related to gastrointestinal symptoms with special reference to excessive straining and discomfort, digital manipulations during defecation, a sense of pelvic heaviness and incomplete evacuation. Each patient underwent clinical examination, anal manometry and defecography during a single outpatient visit. Rectocele (16 patients) was significantly associated with vaginal digitation, lower stool frequency, delayed rectal emptying and decreased rectal sensation to distension. Increased anal pressure on straining (14 patients) was also related to a poor rectal emptying in 13 patients. Neither perineal descent (24 patients) nor external rectal prolapse (12 patients) was related to objective obstruction. Nevertheless there was an association with pelvic heaviness and lower anal manometric recordings. Five among 16 patients with rectocele had manometric anismus. Forty percent of patients with intussusception also had a paradoxical sphincter response during defaecation. Furthermore, associated abnormalities were extremely common (34 of 41 patients), accurate interpretation of which was necessary for planning effective therapy.

Adult↗
PubMed1996

A prospective psychological evaluation of patients with dysphagia of various etiologies.

We hypothesized that patients who complain of dysphagia without demonstrable organic abnormality may have an underlying psychological dysfunction. We thus conducted a comprehensive assessment in three groups of patients with dysphagia. Dysphagia was classified as obstructive (Obst) when an obstructive lesion was present on esophagoscopy or barium swallow, motility-related (Mot) when abnormal motility was shown on esophageal manometry in the presence of normal esophagoscopy or barium swallow, or nonobstructive, nonmotility-related (NONM) when manometry and esophagoscopy or barium swallow were both normal. We prospectively evaluated 71 patients with Obst-dysphagia, 15 patients with Mot-dysphagia and 10 patients with NONM-dysphagia with a battery of standardized psychological tests including the Minnesota Multiphasic Personality Inventory (MMPI), the Symptom Checklist-90-Revised (SCL-90-R), and the Millon Behavioral Health Inventory (MBHI). The results indicate that patients with NONM-dysphagia have psychological attributes similar to those found in patients with Obst-dysphagia or Mot-dysphagia. Combination of scores for parameters such as somatization, depression, and anxiety could not distinguish among the three groups of dysphagia patients. We thus conclude that patients with NONM-dysphagia, as a group, have similar psychological profiles compared to patients with dysphagia due to organic causes.

Adult↗
PubMed1996

Videomanometric aspects of pharyngeal constrictor activity.

Pressure changes were registered with videomanometry (simultaneous manometry and barium swallow) in the pharynx and in the pharyngoesophageal segment (PES) during swallowing. A considerable longitudinal asymmetry was found. Peak pressure was highest in the PES, lower in the inferior constrictor area, and lowest at the level of the tongue base. The rate of pressure rise was highest at the level of the PES. The speed of propagation of the contraction wave was 13 (+/- 2) cm/sec. There was no correlation between the measured variables (i.e., peak pressure, rate of pressure rise, and speed of contracting wave). Our findings can partly be explained by different mechanical constraints at different levels of the pharynx but may also reflect the organization of neural control of swallowing in the brainstem. Knowledge of transducer position and orientation is essential for the evaluation of pharyngeal pressure during swallowing. Such knowledge is best achieved by performing manometry simultaneously with fluoroscopy, i.e., videomanometry.

Adult↗