Recorded lower esophageal pressures as a function of electronic sleeve placement and location of gastric pressure measurement in patients with hiatal hernia

Abstract

Background/aims: In high-resolution manometry lower esophageal sphincter pressure (LESP) is measured relative to intragastric pressure, however Gastric Marker™ (GM) location used to determine resting LESP is not well established with hiatal hernia (HH). We test the hypothesis that measured resting LESP varies with HH based on GM location.

Methods: Subjects with HH ≥ 2 cm were included. The eSleeve™ was adjusted to span only the LES, excluding the crural diaphragm (CD). Resting LESP was determined by placing the GM below and above the CD (in the position yielding the highest resting LESP). Resting pressure across the lower esophageal sphincter (LES) to CD and pressure in the HH relative to subdiaphragmatic intragastric pressure were also measured.

Results: HH ≥ 2 cm was present in 98 patients (mean length 2.7 cm). LESP decreased when GM was moved from below the CD into the HH: respiratory minimum LESP 7.5 ± 1.1 to 3.6 ± 0.9 mmHg; P < 0.001, mean LESP 17.7 ± 1.3 to 13.7 ± 1.1 mmHg; P < 0.001. When the eSleeve encompassed the LES and CD, the respiratory minimum pressure was 12.2 ± 0.9 mmHg and mean pressure was 23.9 ± 1.0 mmHg pressure (P < 0.001 for both). Pressure in the hernia pouch was greater than intragastric pressure: respiratory minimum 3.0 ± 0.7 mmHg and mean 9.0 ± 0.8 mmHg (P < 0.001 for both). pH studies showed a trend toward an association between abnormal distal esophagus acid exposure and lower resting LESP.

Conclusions: GM placement in the HH produces lower resting LESPs. This may provide a more physiologic representation of LESP in HH.

Keywords: Catheters; Esophagus; Gastroesophageal reflux; Hernia, hiatal; Manometry.

Figure 1

Gastric Marker placement below (A) and above (B) the crural diaphragm in hiatal hernia. The Gastric Marker placement is denoted by the blue marker on the right side of the image. Note that the zone within the hernia in this case is greener, denoting higher pressure.

Figure 2

Comparison of placement of Gastric Marker above and below crural diaphragm (CD) in hiatal hernia. Lower esophageal sphincter (LES) minimum and mean pressure were both significantly lower (P < 0.001) with placement of the Gastric Marker above than below the CD.