An improved method of assessing esophageal emptying using the timed barium study following surgical myotomy for achalasia

Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes

Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.

How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia

BACKGROUND

The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities.

PURPOSE

The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.

Achalasia: Diagnosis, Management and Surveillance

Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.

Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response

Background and study aims  The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods  This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm ² /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results  Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P  = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions  Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate

BACKGROUND

Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome.

METHODS

In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score).

KEY RESULTS

Twenty-four achalasics (median age 43 year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P = .03), mean residual barium column height (14.7 ± 8.7 to 7.9 ± 6.0 cm; P = .01) and surface area (52.7 ± 43.5 to 24.5 ± 23.6 cm² ; P = .02). There were 4 (17%) initial non-responders (Eckardt > 3). % SA was best at discriminating between responders and non-responders (area under curve 0.85 ± 0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response.

CONCLUSIONS & INFERENCES

Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.

Implementation of a Timed Barium Esophagram Protocol for Assessment of Esophageal Function in Children

OBJECTIVES

Timed barium esophagram (TBE) is a fluoroscopic study that is widely employed as an adjunctive tool for diagnosing esophageal emptying disorders in adults (eg, achalasia, esophagogastric junction outflow obstruction [EGJOO]) and for following response to treatment. We aimed to describe the characteristics and feasibility of a pediatric TBE protocol and provide a first report of the potential value of TBE for assessment of esophageal emptying in the pediatric population.

METHODS

Retrospective chart review of pediatric patients at a tertiary pediatric hospital who underwent TBE from October 2017 to October 2019. Patient and test characteristics were summarized using descriptive statistics. Results from patients who had both TBE and high-resolution esophageal manometry (HRM) were used to generate ROC curves for TBE to identify esophageal emptying disorders.

RESULTS

Twenty-two patients underwent 25 TBE. Fourteen of 23 (61%) received 150 mL barium volume per protocol. Nearly half (42%) of subjects could tolerate ingesting barium within 20 seconds. Nine individuals underwent HRM. The sensitivity of standard adult TBE criteria (1 cm barium column height at 5 minutes) to detect emptying disorder was 100%, specificity 40%. A modified diagnostic cutoff (1.6 cm height at 5 minutes) offered 100% sensitivity, 80% specificity.

CONCLUSIONS

TBE is feasible and should be considered an adjunctive noninvasive screen for impaired esophageal emptying in children. There was heterogeneous adherence to protocol for timing and volume of barium; however, studies remained interpretable. This population may benefit from different diagnostic cutoffs than adults, and clinical judgment should be used until specific diagnostic cutoffs are determined in children.

Management of primary achalasia: The role of endoscopy

Achalasia is an oesophageal motor disorder which leads to the functional obstruction of the lower oesophageal sphincter (LES) and is currently incurable. The main objective of all existing therapies is to achieve a reduction in the obstruction of the distal oesophagus in order to improve oesophageal transit, relieve the symptomatology, and prevent long-term complications. The most common treatments used are pneumatic dilation (PD) and laparoscopic Heller myotomy, which involves partial fundoplication with comparable short-term success rates. The most economic non-surgical therapy is PD, with botulinum toxin injections reserved for patients with a higher surgical risk for whom the former treatment option is unsuitable. A new technology is peroral endoscopic myotomy, postulated as a possible non-invasive alternative to surgical myotomy. Other endoluminal treatments subject to research more recently include injecting ethanolamine into the LES and using a temporary self-expanding metallic stent. At present, there is not enough evidence permitting a routine recommendation of any of these three novel methods. Patients must undergo follow-up after treatment to guarantee that their symptoms are under control and to prevent complications. Most experts are in favour of some form of endoscopic follow-up, however no established guidelines exist in this respect. The prognosis for patients with achalasia is good, although a recurrence after treatment using any method requires new treatment.

High-resolution manometry is comparable to timed barium esophagogram for assessing response to pneumatic dilation in patients with achalasia

BACKGROUND

Reduction in height of barium column in timed barium esophagogram (TBE) and lower esophageal sphincter (LES) pressure on manometry has been used to assess efficacy of pneumatic dilation (PD) in patients with achalasia; data comparing these two methods to assess efficacy of PD are scanty.

METHODS

Sixty-two patients with achalasia undergoing PD were evaluated clinically (Eckardt's score), high-resolution manometry (HRM), and TBE (films at 1 and 5 min) before and 4 weeks after PD using 30 and 35 mm Rigiflex balloon (Microvasive, Milliford, MA, USA) in female and male patients, respectively. Response was defined clinically as Eckardt's score <3, by manometry as LES pressure <22.5 mmHg, and by TBE as adequate esophageal emptying (reduction in height of barium column by more than 50 % of pretreatment value in 5-min radiograph).

RESULTS

Forty-three out of sixty-two (69 %) patients [age 34 ± 12 years, 36 (58 %) male] responded, and 19 (31 %) did not respond to the first session of PD as assessed by post-PD Eckardt's score. Thirty-eight out of 43 (88 %) responders had adequate esophageal emptying of barium in TBE, while 31/43 (72 %) had LES pressure below 22.5 mmHg on HRM (p = ns). Eight out of 19 (42 %) nonresponders showed failure in esophageal emptying (defined by lack of reduction in height of barium column by 50 %) in TBE, and 11/19 (58 %) had LES pressure >22.5 mmHg (p = ns). Kaplan-Meier analysis showed that response on TBE and HRM at 1 month predicted clinical response well during 6 months follow up.

CONCLUSION

TBE and esophageal HRM were comparable in assessing efficacy of PD in treatment of achalasia.

The role of barium esophagography in an endoscopy world

Barium esophagography, although an old test, remains important to the understanding of esophageal physiology and diagnosis of esophageal disorders. It provides additive and/or confirmatory information to endoscopy and is the more accurate means of yielding diagnosis. Barium esophagography allows correlation of symptoms with barium findings and with varied textures substances. It allows, particularly for oropharyngeal dysfunction, implementation therapeutic maneuvers and instructions while testing. The caveat to maintaining the benefits of barium esophagography is continuing to promote and support expertise from our radiologists in performing these studies, which has been challenged by our cost-efficient and high-tech medical society.

How to perform and interpret timed barium esophagogram

Timed barium esophagogram (TBE) is a simple and objective method for assessing the esophageal emptying. The technique of TBE is similar to usual barium swallow with some modifications, which include taking multiple sequential films at pre-decided time interval after a single swallow of a fixed volume of a specific density barium solution. While many authors have used height and width of the barium column to assess the esophageal emptying, others have used the area of the barium column. TBE is being used in patients with suspected or confirmed achalasia and to follow-up those who have been treated with pneumatic dilation or myotomy. This review discusses technique of performing TBE, interpretation and its utility in clinical practice.

Treatment and surveillance strategies in achalasia: an update

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.

Effect of laparoscopic esophagomyotomy on chest pain associated with achalasia and prediction of therapeutic outcomes

BACKGROUND

The effect of myotomy for achalasia on chest pain has not been clarified. The current study aimed to investigate the therapeutic effect of laparoscopic myotomy on chest pain associated with achalasia and to identify prognostic factors for outcomes.

METHOD

Between March 2005 and September 2008, 95 patients were available for detailed interviews and for assessment of clearance by timed barium esophagogram (TBE) before and after surgery. Of the 95 patients, 47 (24 men; mean age, 42.9 ± 13.5 years) who experienced chest pain before surgery were studied. The subjects were asked in detail about dysphagia and chest pain before surgery and 6 months after surgery. The frequency and severity of the symptoms were graded on a scale of 0 to 4. In addition, the values obtained by multiplying the grade for frequency by the grades for severity of the two symptoms were defined as the dysphagia score and the chest pain score, respectively. The patients with chest pain scores of 0 after surgery were defined as group A and those with scores smaller than their preoperative scores as group B. The remaining patients with other scores were defined as group C. The background factors and clinical conditions of the three groups were compared.

RESULTS

The mean chest pain score decreased from 5.0 ± 3.2 to 1.0 ± 1.6 (p < 0.001). The score after surgery was 0 for 27 patients and showed a decrease for 15 patients. Although the three groups did not differ in their characteristics, differences were noted in postoperative TBE factors (i.e., groups A and B had significantly shorter barium columns than group C at 1 and 5 min after surgery (p = 0.001).

CONCLUSION

Laparoscopic myotomy had a therapeutic effect on chest pain associated with achalasia, and improvement in postoperative esophageal clearance may influence the therapeutic effect.

A controversy that has been tough to swallow: is the treatment of achalasia now digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.