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Characterization of Esophageal Motility in Infants With Congenital Diaphragmatic Hernia Using High-resolution Manometry

Rayyan, Maissa*,†; Omari, Taher; Debeer, Anne*,†; Decaluwe, Herbert§; Deprest, Jan†,||,¶; Allegaert, Karel†,#; Rommel, Nathalie**,††,‡‡

Journal of Pediatric Gastroenterology and Nutrition: July 2019 - Volume 69 - Issue 1 - p 32–38
doi: 10.1097/MPG.0000000000002325
Original Articles: Gastroenterology

Objectives: The aim of the study was to characterize esophageal motility and esophagogastric junction (EGJ) function in infants who underwent repair of an isolated congenital diaphragmatic hernia (iCDH).

Methods: High-resolution manometry with impedance was used to investigate esophageal motility and EGJ function after diaphragmatic repair in 12 infants with iCDH (11 left-sided; 9 patch repair). They had esophageal motility studies during neonatal admission (n = 12), at 6 months (n = 10) and at 12 months of life (n = 7). Swallows were analyzed using conventional esophageal pressure topography and pressure flow analysis and were compared with 11 healthy preterm born infants at near-term age.

Results: Esophageal peristaltic motor patterns in patients with iCDH were comparable to controls. EGJ end-expiratory pressure was higher in patients with patch repair compared with controls (P = 0.050) and those without patch (P = 0.009). The difference between inspiratory and expiratory pressures at the EGJ was lower in patients with iCDH with patch (P = 0.045) compared to patients without. Patients with iCDH with patch showed increased Pressure Flow Index, resistance of bolus flow at the EGJ, compared with controls (P = 0.043).

Conclusions: Normal esophageal wave patterns are present in the investigated patients with iCDH. EGJ end-expiratory pressure seems lower in patients with iCDH without patch suggesting a decreased EGJ barrier function hence increased vulnerability to gastroesophageal reflux. Patch repair appears to increase end-expiratory pressure at the EGJ above that of controls suggesting that patch surgery tightens the EGJ, thereby increasing flow resistance. This is in line with the increased Pressure Flow Index. In infants with a patch, the inspiration-expiration pressure difference is lower, reflecting diminished activity of the crural diaphragm.

*Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven

Academic Department of Development and Regeneration, KU Leuven, Belgium

College of Medicine and Public Health, Flinders University, Adelaide, Australia

§Department of Thoracic Surgery, University Hospitals Leuven

||Clinical Department of Obstetrics and Gynecology, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium

Institute for Women's Health, University College London, London, UK

#Department of Pediatrics, Division of Neonatology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands

**Department of Neurosciences, Experimental Oto-Rhino-Laryngology, Deglutology, KU Leuven

††Neurogastroenterology and Motility, Gastroenterology, University Hospitals Leuven

‡‡Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), Leuven, Belgium.

Address correspondence and reprint requests to Maissa Rayyan, MD, Neonatal Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium (e-mail:

Received 11 November, 2018

Accepted 14 February, 2019

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (

M.R. is supported by the fund for clinical research, University Hospitals Leuven, Belgium. J.D. is supported by a grant of the Great Ormond Street Hospital Charity Fund. University Hospitals Leuven and Erasmus Medical Centre are members of the European Reference Network “ERNICA.”

N.R. and T.O. hold a patent on AIMplot, the software used to analyze the pressure flow data. The remaining authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (

© 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,