2 e-Letters

  • Foxresponse

    We would like to thank professor Fox for his keen interest in our work, his incisive comments and physiologic clarifications. We do agree that there is a lot of work that will be required to clarify the nature and clinical implications of esophago-gastric junction outflow obstruction (EGJOO).


    While motor physiologists are deciphering the manometric features, mechanisms and possible ramifications, clinicians need to know what to do with the information they receive on a high resolution manometric (HRM) report and patients need help with their symptoms. By sub-classifying EGJOO, our study attempts to facilitate clinical decisions that would potentially help both clinicians and patients. For example, in isolated (classic) EGJOO, balloon dilation of the EGJ could be one clinical option, while in a case of EGJOO with diffuse esophageal spasm (DES), botulinum toxin injection of the EGJ and the distal esophagus might be more appropriate and clinically useful. Prospective, multicenter trials performed on better defined manometric phenotypes, such as the ones we proposed in our study, will be essential, but they will also be hampered by the fluidity of the HRM diagnosis that we reported.


    The HRM community is looking forward to further fine-tuning of the Chicago classification that will open-mindedly incorporate such concepts and eventually lead to more precise manometric diagnosis and clinically useful interventions.

  • EGJ outlet obstruction: : towards a new classification

    Triadafilopoulos and Clarke present a retrospective assessment of high-resolution manometry (HRM) in patients with oesophago-gastric junction outlet obstruction (EGJOO; 116/ 478 (24%) consecutive patients).1 Overall, “only” 38% patients had EGJOO (IRP >15mmHg with preserved peristalsis), 12% received a final diagnosis of achalasia and 50% had “elements” of other manometric diagnoses (spasm, hypercontractile or ineffective motility). Based on this data the authors suggest that the current diagnosis of EGJOO requires refinement and a new classification of EGJOO subtypes is proposed.

    Similar to the three types of achalasia recognized by the Chicago Classification version 3 (CCv.3),2 the presence or absence of peristaltic abnormalities with EGJOO could indicate different underlying etiology and guide treatment decisions.3, 4 However, as yet, the data presented does not provide sufficient support for this proposal. Patients with EGJOO with and without other coexisting manometric findings were indistinguishable based on clinical characteristics. Further, clearance function assessed by concurrent high-resolution impedance was impaired to a similar extent in all subgroups.

    The Chicago Classification is a hierarchical system based on mechanical principles.2 Disorders of EGJ motility and function are prioritized because disorders of motility (e.g. spasm, ineffective motility) have less impact on bolus transport that impaired relaxation or opening of the lower oeso...

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