The Chicago classification for achalasia in a French multicentric cohort

Comparison of Endoscopic Dilatation and Heller's Myotomy for Treating Esophageal Achalasia in Children: A Multicenter Study

OBJECTIVE

To compare the efficacy of, and complications from, the 2 main treatments for achalasia: endoscopic dilatation and surgical cardiomyotomy (Heller's myotomy).

STUDY DESIGN

We retrospectively collected data on children treated for achalasia over an 11-year period from 8 tertiary pediatric centers. A line of treatment was defined as performing either Heller's myotomy or 1-3 sessions of endoscopy dilatation over 3 months. Treatment success was a priori defined as clinical improvement and no need for new treatment.

RESULTS

Ninety-seven children (median age, 12 years; 57% boys) were included. The median time to diagnosis was 10.5 months, and the median follow-up period was 27 months. Thirty-seven children were treated by Heller's myotomy and 60 by endoscopy dilatation as the first-line treatment. After adjustment for potentially confounding factors, Heller's myotomy was significantly more successful than endoscopy dilatation (hazard ratio, 3.93 [1.74; 8.88]; P = .001), with a median survival without failure of 49 and 7 months, respectively, and with no significant difference in the occurrence of complications (35.2% for Heller's myotomy, 29.7% for endoscopy dilatation, P = .56). Hydrostatic dilatation was as successful as pneumatic dilatation (hazard ratio, 1.35 [0.56; 3.23]; P = .50).

CONCLUSIONS

Heller's myotomy is more successful than endoscopy dilatation, with no significant difference in the occurrence of serious complications. This raises the potential role of peroral endoscopic myotomy as an alternative treatment to Heller's myotomy.

Differences in upper esophageal sphincter function and clinical characteristics among the three subtypes of Japanese patients with esophageal achalasia

BACKGROUND

The rarity of esophageal achalasia has resulted in little being known about the characteristics of its three subtypes. The upper esophageal sphincter is considered one key factor to prevent aspiration pneumonia, a serious complication of esophageal achalasia. This study aimed to reveal the subtype characteristics of esophageal achalasia and how the upper esophageal sphincter functions and relates to other clinical parameters of the disease.

METHODS

We retrospectively investigated the clinical records of patients diagnosed with esophageal achalasia. All participants underwent esophagogastroduodenoscopy and then, within 2 weeks, high-resolution manometry. Gastrointestinal symptoms were assessed using a previously validated self-reported questionnaire.

RESULTS

A total of 110 patients with esophageal achalasia were enrolled: 50 with type I, 40 with type II, and 20 with type III. Mean age at diagnosis was 54.5, 50.4, and 66.1 years for types I, II, and III, respectively. Mean resting upper esophageal sphincter pressure was 28.0, 51.8, and 43.6 mmHg for patients with types I, II, and III, respectively (p < 0.01). Patients with type III esophageal achalasia more frequently reported stomachache than those with type I (p = 0.03). A negative correlation between resting upper esophageal sphincter pressure and age was observed in all subtypes.

CONCLUSIONS

A negative correlation was confirmed between resting upper esophageal sphincter pressure and age in all subtypes of esophageal achalasia. Type III patients were older at diagnosis, type II patients showed higher upper esophageal sphincter pressure, and type I patients showed a lower upper esophageal sphincter pressure at the early life stage.

Efficacy and safety of peroral endoscopic myotomy in 100 older patients

BACKGROUND

Peroral endoscopic myotomy (POEM) is a standard treatment for achalasia. Several reports have described the efficacy and safety of POEM for elderly patients, but none has reported the efficacy and safety of POEM in a large number of elderly patients for > 3 years postoperatively. In this study, we examined the safety and outcome of POEM for 3 years postoperatively in 100 elderly patients.

METHODS

One hundred consecutive patients aged > 65 years who underwent POEM from September 2011 to March 2020 were included in this study. In analysis 1, we retrospectively investigated the safety and efficacy of POEM in all patients. In analysis 2, the efficacy and safety of POEM were statistically compared between two groups: the early elderly (65-74 years of age, 55 patients) and late elderly (≥ 75 years of age, 45 patients).

RESULTS

The technical success rate of POEM was 100%. In analysis 1, the 3-month, 1-year, 2-year, and 3-year efficacies of POEM (Eckardt score of ≤ 3) were 100% (92/92 cases), 100% (91/91 cases), 97.8% (88/90 cases), and 100% (92/92 cases), respectively. Procedure-related adverse events occurred in 11% of patients, but none was fatal. Two late elderly patients developed aspiration pneumonia due to delirium and underwent long-term hospitalization. In analysis 2, there were no significant differences in the efficacy and safety of POEM between the two age groups.

CONCLUSIONS

POEM is effective and safe for elderly patients. However, precautions are needed regarding the risk of adverse events associated with delirium when POEM is performed in elderly patients.

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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Changes in the Treatment of Primary Esophageal Motility Disorders Imposed by the New Classification for Esophageal Motility Disorders on High Resolution Manometry (Chicago Classification 4.0)

The Chicago Classification is the most used classification for primary esophageal motility disorders (PEMD). This classification was recently updated to the 4.0 version. This opinion piece focuses on the possible implications for the treatment of PMED determined by the new classification. Chicago Classification 4.0 included two new concepts for the diagnosis of achalasia: (1) type III achalasia diagnosis demands 100% absent peristalsis defined as either failed peristalsis or spasm; (2) “inconclusive diagnosis of achalasia” was added as a possibility. Both may decrease unnecessary treatment. Esophagogastric junction outflow obstruction, distal esophageal spasm, and hypercontractile esophagus were only considered clinically significant when correlated to supportive testing and relevant clinical symptoms and in the absence of gastroesophageal reflux disease. This may decrease the surge of treatment, especially peroral endoscopic myotomy, based solely on manometric diagnosis.

AGA Clinical Practice Update on Functional Heartburn: Expert Review

BEST PRACTICE ADVICE 1: A diagnosis of functional heartburn should be considered when retrosternal burning pain or discomfort persists despite maximal (double-dose) proton pump inhibitor (PPI) therapy taken appropriately before meals during a 3-month period. BEST PRACTICE ADVICE 2: A diagnosis of functional heartburn requires upper endoscopy with esophageal biopsies to rule out anatomic and mucosal abnormalities, esophageal high-resolution manometry to rule out major motor disorders, and pH monitoring off PPI therapy (or pH-impedance monitoring on therapy in patients with proven gastroesophageal reflux disease [GERD]), to document physiologic levels of esophageal acid exposure in the distal esophagus with absence of reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 3: Overlap of functional heartburn with proven GERD is diagnosed according to Rome IV criteria when heartburn persists despite maximal PPI therapy in patients with history of proven GERD (ie, positive pH study, erosive esophagitis, Barrett's esophagus, or esophageal ulcer), and pH impedance testing on PPI therapy demonstrates physiologic acid exposure without reflux-symptom association (ie, negative symptom index and symptom association probability). BEST PRACTICE ADVICE 4: PPIs have no therapeutic value in functional heartburn, the exception being proven GERD that overlaps with functional heartburn. BEST PRACTICE ADVICE 5: Neuromodulators, including tricyclic antidepressants, selective serotonin reuptake inhibitors, tegaserod, and histamine-2 receptor antagonists have benefit as either primary therapy in functional heartburn or as add-on therapy in functional heartburn that overlaps with proven GERD. BEST PRACTICE ADVICE 6: Based on available evidence, acupuncture and hypnotherapy may have benefit as monotherapy in functional heartburn, or as adjunctive therapy combined with other therapeutic modalities. BEST PRACTICE ADVICE 7: Based on available evidence, anti-reflux surgery and endoscopic GERD treatment modalities have no therapeutic benefit in functional heartburn and should not be recommended.

Value of Multidetector Computed Tomography in the Assessment of Achalasia Subtypes and Detection of Pulmonary and Thoracic Complications

OBJECTIVE

To evaluate multidetector computed tomography (MDCT) findings in patients with achalasia, to assess its role in differentiating subtypes in detecting lung involvement and extra-esophageal thoracic complications.

SUBJECTS AND METHODS

This clinical retrospective study included 51 patients with manometrically confirmed achalasia who underwent chest X-ray and MDCT in diagnostic work-up. Esophageal wall thickness and morphology, luminal dilatation, lung changes, and extra-esophageal manifestations were analyzed on MDCT by 2 readers. Wilcoxon, Kruskal-Wallis and Mann-Whitney test were used for assessing the differences among the achalasia subtypes, and intra-class correlation coefficients (ICC) assessing the inter-observer agreement between the measurements of 2 readers.

RESULTS

Fourteen (27.5%) patients had achalasia subtype I, 21 (60.8%) had subtype II while 6 (11.8%) had subtype III. Esophageal wall thickness of the esophageal body (EB) and distal esophageal segment (DES) as well as nodular/lobulated appearance of DES were found significantly more often in subtype III (p = 0.024, p < 0.001, p = 0.009, respectively). Esophageal dilatation gradually decreased from subtype I to III (p = 0.006). Chest X-ray revealed lung changes in 9 (17%) and MDCT in 21 (41%) patients (p = 0.001), most frequently in subtype I, with predominance of ground-glass opacities. Tracheal/carinal compression was detected in 27 (52.9%) and left atrial compression in 17 (33.3%) patients. Excellent inter-observer agreement was observed in measuring the EB and DES wall thickness, and diameter of EB (ICC 0.829, 0.901, and 0.922).

CONCLUSION

MDCT is a useful tool for detecting lung and extra-esophageal thoracic complications in patients with achalasia, and could be a valuable additional imaging modality in the differentiation of achalasia subtypes.

Comparison of the Outcomes of Peroral Endoscopic Myotomy for Achalasia According to Manometric Subtype

Background/Aims

We evaluated whether manometric subtype is associated with treatment outcome in patients with achalasia treated by peroral endoscopic myotomy (POEM).

Methods

High-resolution manometry data and Eckardt scores were collected from 83 cases at two tertiary referral centers where POEM is performed. Manometric tracings were classified according to the three Chicago subtypes.

Results

Among the 83 cases, 48 type I, 24 type II, and 11 type III achalasia cases were identified. No difference was found in pre-POEM Eckardt score, basal lower esophageal sphincter (LES) pressure, or integrated relaxation pressure (IRP) among the type I, type II, and type III groups. All three patient groups showed a significant improvement in post-POEM Eckardt score (6.1±2.1 to 1.5±1.5, p=0.001; 6.8±2.2 to 1.2±0.9, p=0.001; 6.6±2.0 to 1.6±1.4, p=0.011), LES pressure (26.1±13.8 to 15.4±6.8, p=0.018; 32.3±19.0 to 19.2±10.4, p=0.003; 36.8±19.2 to 17.5±9.7, p=0.041), and 4s IRP (21.5±11.7 to 12.0±8.7, p=0.007; 24.5±14.8 to 12.0±7.6, p=0.002; 24.0±15.7 to 11.8±7.1, p=0.019) at a median follow-up of 16 months.

Conclusions

POEM resulted in a good clinical outcome for all manometric subtypes.

Pneumatic Balloon Dilatation for Achalasia Cardia: Outcome, Complications, Success, and Long-term Follow-up

Background:

Achalasia is a chronic disease that can be managed with effective endoscopic modalities.

Aim:

To evaluate the effectiveness of single setting of pneumatic balloon dilatation for achalasia and assess the long-term success and outcomes.

Materials and methods:

This is a retrospective study of all achalasia patients who underwent pneumatic balloon dilatation at our institute. Patients who could be contacted were inquired regarding their symptoms and dysphagia-free interval after dilatation.

Results:

A total of 72 patients were enrolled. Out of this, 14 patients lost to follow-up. Mean age of 58 patients was 45.02 ± 16.51 years. Male:female ratio was 13:16. Mean predilatation Eckardt score was 7.16 ± 0.834. Type I achalasia was present in 10 (17.2%), type II in 44 (75.9%), type III in 4 (6.9%). Predilatation basal integrated relaxation pressure (IRP) was 28.14 ± 14.76 mm Hg. Postdilatation Eckardt score was 2.40 ± 1.67. Postdilatation dysphagia-free interval was 17.28 ± 6.70 months. A total of 9 patients (15.51%) failed to respond to first dilatation and 49 (84.48%) patients benefited from single setting of pneumatic dilatation. Esophageal perforation occurred in 2/58 (3.44%). We did not find any significant difference in gender distribution, age of presentation, duration of symptom, pre- and postdilatation Eckardt score, type of achalasia, and basal IRP on manometry between type of achalasia. Postdilatation dysphagia-free interval in type II achalasia (18.09 ± 5.976 months) was more than types I and III achalasia cardia (p = 0.066), which showed trend toward significance.

Conclusion:

Pneumatic balloon dilatation of achalasia cardia is a highly effective endoscopic procedure with minimal complications and mortality. Even the single setting of dilatation can have long-lasting dysphagia-free interval.

How to cite this article: Gupta SJ, Gaikwad NR, Samarth AR, Gattewar SR. Pneumatic Balloon Dilatation for Achalasia Cardia: Outcome, Complications, Success, and Long-term Follow-up. Euroasian J Hepato-Gastroenterol 2017;7(2):138-141.

Difference of achalasia subtypes based on clinical symptoms, radiographic findings, and stasis scores

INTRODUCTION

Three subtypes of achalasia have been defined through high-resolution esophageal manometry: subtype i shows no pressurization with swallows, subtype ii has increased isobaric panesophageal pressure, and subtype iii has distal esophageal spastic non-isobaric contractions. Studies describing the subtypes based on radiographic findings, clinical symptoms, and stasis scores are limited.

AIM

To determine the differences in clinical symptoms, radiographic findings, and stasis scores for the 3 achalasia subtypes.

METHODS

Patients undergoing high-resolution esophageal manometry received a questionnaire about current symptoms and previous treatments. The questions included the presence of symptoms and their severity. Barium swallow tests were performed before the high-resolution esophageal manometry study to evaluate the maximum esophageal diameter. Stasis scores were calculated using the transit patterns on high-resolution esophageal manometry.

RESULTS

One hundred and eight patients with high-resolution esophageal manometry diagnosis of achalasia (n=8, subtype i; n=84, subtype ii; n=16, subtype iii) within the time frame of 1/2012-6/2015 were included in the study. Sex distribution was similar between the subtypes. Patient age was younger for subtype i (38±16 years), compared with subtypes ii (55±17 years) and iii (63±17 years) (P=.03). Esophageal symptoms did not differ between subtypes regarding the severity of nausea, chest pain, coughing, and heartburn, except for increased vomiting severity in subtype i (2.8±1.4 vs. 1.4±1.4 vs. 1.2±1.2, P<.01). A significant radiographic difference in esophageal dilation was seen between subtypes ii and iii (35.1±14.4 vs. 24.0±7.2mm, P=.023). Stasis scores did not significantly differ between the subtypes.

CONCLUSIONS

Achalasia subtypes had similar clinical symptoms, except for increased vomiting severity in subtype i. The maximum esophageal diameter in subtype ii was significantly greater than in subtype iii. Esophageal stasis scores were similar. Thus, high-resolution esophageal manometry remains essential in assessing achalasia subtypes.

Clinical Outcomes and Safety of Partial Full-Thickness Myotomy versus Circular Muscle Myotomy in Peroral Endoscopic Myotomy for Achalasia Patients

Background. Here we aimed to evaluate and compare the efficacy and safety between partial full-thickness myotomy and circular muscle myotomy during POEM procedure in achalasia patients. Methods. Clinical data of achalasia of cardia (AC) patients who underwent POEM in our center during January 2014 to January 2015 was collected (34 cases). 19 patients who received partial full-thickness myotomy were assigned to group A and 14 patients who received circular muscle myotomy were assigned to group B. The procedure-related parameters between the two groups were compared. Symptom relief rate and postprocedure manometry outcomes were compared to evaluate the efficacy. Procedure-related adverse events and complications were compared to evaluate the safety. Results. (1) Mean operation times were significantly shorter in group A than group B (62.42 ± 23.17 vs 87.86 ± 26.44 min, p < 0.01). (2) Symptom relief rate and postprocedure manometry outcomes had no statistical differences when compared between the two groups (all p > 0.05). (3) Comparison of procedure-related adverse events and complications had no statistical differences (all p > 0.05). Conclusion. Partial full-thickness myotomy had no significant differences in efficacy or safety with circular myotomy, but partial full-thickness myotomy significantly reduced the procedure time.

Evaluation of outcome after cardiomyotomy for achalasia using the Chicago classification

Background

Achalasia can be subdivided into manometric subtypes according to the Chicago classification. These subtypes are proposed to predict outcome after treatment. This hypothesis was tested using a database of patients who underwent laparoscopic Heller's cardiomyotomy with anterior fundoplication.

Methods

All patients who underwent Heller's cardiomyotomy for achalasia between June 1993 and March 2015 were identified from an institutional database. Manometry tracings were retrieved and re-reported according the Chicago classification. Outcome was assessed by a postal questionnaire, and designated a success if the modified Eckardt score was 3 or less, and the patient had not undergone subsequent surgery or pneumatic dilatation. Difference in outcome after cardiomyotomy was analysed with a mixed-effects logistic regression model.

Results

Sixty, 111 and 24 patients had type I, II and II achalasia respectively. Patients with type III achalasia were more likely to be older than those with type I or II (mean age 63 versus 50 and 49 years respectively; P = 0·001). Some 176 of 195 patients returned questionnaires after surgery. Type III achalasia was less likely to have a successful outcome than type II (odds ratio (OR) 0·38, 95 per cent c.i. 0·15 to 0·94; P = 0·035). There was no significant difference in outcome between types I and II achalasia (II versus I: OR 0·87, 0·47 to 1·60; P 0·663). The success rate at 3-year follow-up was 69 per cent (22 of 32) for type I, 66 per cent (33 of 50) for type II and 31 per cent (4 of 13) for type III.

Conclusion

Type III achalasia is a predictor of poor outcome after cardiomyotomy. There was no difference in outcome between types I and II achalasia.

Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes

BACKGROUND

Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy-Heller myotomy (HM)-is employed.

METHODS

Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20 % swallows; subtype III: premature contractions in ≥20 % swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0 = no symptoms, 4 = severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes.

RESULTS

Sixty achalasia subjects (56.1 ± 2.4 years, 55 % female) fulfilled inclusion criteria, 15 % with subtype I, 58 % with subtype II, and 27 % with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85 %, liquids: 73 %), regurgitation (84 %), and chest pain (35 %); mean GSS was 7.1 ± 0.3. Upon follow-up 2.1 ± 0.2 years after HM, GSS declined to 1.9 ± 0.4 (p < 0.001), with surgical satisfaction score of 8.7 ± 0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender (p = 0.003) and dysphagia for liquids (p = 0.043) remained predictive on multivariate analysis.

CONCLUSIONS

When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.

Esophagogastric junction distensibility in the management of achalasia patients: relation to treatment outcome

BACKGROUND

Achalasia is characterized by a functional esophagogastric junction (EGJ) obstruction. The functional luminal imaging probe (EndoFLIP) is a method to assess EGJ distensibility. In a homogeneous group of newly diagnosed achalasia patients treated with pneumatic dilation (PD), we aimed (i) to determine whether the assessment of EGJ distensibility has added value in the management of achalasia patients and (ii) to evaluate whether EGJ distensibility differs between achalasia subtypes.

METHODS

Twenty-six newly diagnosed achalasia patients were treated by graded PD (30 and 35 mm) separated by 1 week. EGJ distensibility was measured with the EndoFLIP technique before and after 30 mm PD. Good clinical outcome was defined as an Eckardt score <4 at 1-year follow-up. Fifteen healthy controls underwent an EndoFLIP measurement as control group.

KEY RESULTS

Newly diagnosed achalasia patients had reduced EGJ distensibility compared to healthy controls (0.9 [0.7-1.5] vs 3.4 [2.7-4.2] mm(2) /mmHg, p < 0.01), and EGJ distensibility was lower in type II compared to type I patients (0.8 [0.7-1.1] vs 1.5 [0.9-1.9] mm(2) /mmHg, p = 0.02). EGJ distensibility was increased after PD from 0.9 (0.7-1.5) to 4.2 (3.0-5.7) mm(2) /mmHg (p < 0.001). No difference was found in EGJ distensibility directly after PD between patients with good and poor clinical outcome at 1-year follow-up.

CONCLUSIONS & INFERENCES

Assessment of EGJ distensibility with the EndoFLIP technique is able to demonstrate the functional EGJ obstruction in newly diagnosed achalasia patients and EGJ distensibility differs between achalasia subtypes. Although PD improves EGJ distensibility, assessment of EGJ distensibility with a limited number of distension steps provides no additional information that is useful for clinical evaluation and management of achalasia patients.

High resolution manometry analysis of esophageal motility characteristics in patients with different subtypes of achalasia

AIM: To investigate the esophageal motility characteristics by high resolution manometry (HRM) in patients with different subtypes of achalasia categorized by 2014 Chicago classification criteria.

METHODS: Thirty untreated achalasia patients referred to our clinic between March 2014 and December 2014 were enrolled for HRM examination and typing by the Chicago classification criteria. The esophageal motility characteristics of different subtypes of achalasia were analyzed.

RESULTS: Of the 30 achalasia patients, 7 (23.3%) were classified as having subtype Ⅰ, 19 (63.3%) as having subtype Ⅱ and 4 (13.3%) as having subtype Ⅲ. No significant difference was found among the three subtypes in lower esophageal sphincter (LES) resting pressure, average LES length, average intraabdominal LES length and integrated relaxation pressure (IRP) (P > 0.05). The percentage of patients with panesophageal pressurization in subtype Ⅱ patients was 91.76% ± 3.12%, significantly higher than that of subtype Ⅲ patients (53.33% ± 11.81%, P < 0.05). Compared to subtype Ⅰ patients, upper esophageal sphincter (UES) resting pressure was significantly higher in subtype Ⅱ patients (65.74 mmHg ± 5.21 mmHg vs 38.73 mmHg ± 3.37 mmHg, P < 0.05), but no significant difference was noted between subtypes Ⅰ and Ⅲ or between subtypes Ⅱ and Ⅲ. Although no significant difference was found among the three subtypes in UES residual pressure, in subtype Ⅱ, UES residual pressure was 13.41 mmHg ± 1.55 mmHg, higher than normal value (12 mmHg), which means abnormal relaxation of UES.

CONCLUSION: In patients with achalasia, subtype Ⅱ is more common. Subtype Ⅱ patients often exhibit LES relaxation disorder, panesophageal pressurization, UES resting pressure increase and UES abnormal relaxation. HRM contributes to early diagnosis and accurate classification and thus helps to make proper treatment choices.

Clinical, endoscopic, and radiologic features of three subtypes of achalasia, classified using high-resolution manometry

BACKGROUND/AIMS

High-resolution manometry (HRM) has improved the accuracy of manometry in detecting achalasia and determining its subtypes. However, the correlation of achalasia subtypes with clinical, endoscopic, and radiologic findings has not been assessed. We aimed to evaluate and compare the clinical, endoscopic, and fluoroscopy findings associated with three subtypes of achalasia using HRM.

PATIENTS AND METHODS

The retrospective clinical data, HRM, endoscopy, and radiologic findings were obtained from the medical records of untreated achalasia patients.

RESULTS

From 2011 to 2013, 374 patients underwent HRM. Fifty-two patients (14%) were diagnosed with achalasia, but only 32 (8.5%) of these patients had not received treatment and were therefore included in this study. The endoscopy results were normal in 28% of the patients, and a barium swallow was inconclusive in 31% of the achalasia patients. Ten patients (31%) were classified as having type I achalasia, 17 (53%) were classified as type II, and 5 (16%) were classified as type III. Among the three subtypes, type I patients were on average the youngest and had the longest history of dysphagia, mildest chest pain, most significant weight loss, and most dilated esophagus with residual food. Chest pain was most common in type III patients, and frequently had normal fluoroscopic and endoscopic results.

CONCLUSION

The clinical, radiologic, and endoscopic findings were not significantly different between patients with type I and type II untreated achalasia. Type III patients had the most severe symptoms and were the most difficult to diagnose based on varied clinical, radiologic, and endoscopic findings.

High resolution manometry sub-classification of Achalasia: does it really matter? Does Achalasia sub-classification matter?

BACKGROUND

Three variants of Achalasia have been described using high-resolution esophageal manometry (HRM). While manometrically distinct, their clinical significance has yet to be established. Our objective was to compare the outcome after myotomy in patients with these Achalasia subtypes.

METHODS

A retrospective chart review was performed to identify patients with Achalasia who had HRM and who underwent Heller myotomy or Per oral endoscopic myotomy (POEM). Symptoms and esophageal clearance by timed barium study were compared before and after treatment.

RESULTS

We identified 49 patients, 21 males and 28 females, with a median age of 52 years. The primary symptom in all patients was dysphagia, with a median duration of 4 years (range 4 months-50 years). By HRM, ten patients (20 %) were classified as Type I, 30 (61 %) as Type II, and 9 (18 %) as Type III. At a median follow-up of 16 months after myotomy (range 1-63 months), the median Eckardt score was zero and was similar across subtypes. Relief of dysphagia was also similar across subtypes (80 % of Type I, 93 % of Type II and 89 % of Type III). On pre-treatment timed barium study, no patient had complete emptying at 1 or 5 min. After myotomy, complete emptying occurred within 1 min in 50 % (20/40) and within 5 min in 60 % (24/40) and was similar across groups.

CONCLUSION

Myotomy for Achalasia results in excellent symptomatic outcome and improvement in esophageal clearance. There was no difference among the described HRM Achalasia variants. This calls into question the clinical utility of Achalasia sub-classification and affirms the benefit of myotomy for this disease.

Upper esophageal sphincter abnormalities are strongly predictive of treatment response in patients with achalasia

AIM: To investigate the relationship between upper esophageal sphincter abnormalities achalasia treatment

METHODS: We performed a retrospective study of 41 consecutive patients referred for high resolution esophageal manometry with a final manometric diagnosis of achalasia. Patients were sub-divided by presence or absence of Upper esophageal sphincter (UES) abnormality, and clinical and manometric profiles were compared. Correlation between UES abnormality and sub-type (i.e., hypertensive, hypotensive or impaired relaxation) and a number of variables, including qualitative treatment response, achalasia sub-type, co-morbid medical illness, psychiatric illness, surgical history, dominant presenting symptom, treatment type, age and gender were also evaluated.

RESULTS: Among all 41 patients, 24 (58.54%) had a UES abnormality present. There were no significant differences between the groups in terms of age, gender or any other clinical or demographic profiles. Among those with UES abnormalities, the majority were either hypertensive (41.67%) or had impaired relaxation (37.5%) as compared to hypotensive (20.83%), although this did not reach statistical significance (P = 0.42). There was no specific association between treatment response and treatment type received; however, there was a significant association between UES abnormalities and treatment response. In patients with achalasia and concomitant UES abnormalities, 87.5% had poor treatment response, while only 12.5% had favorable response. In contrast, in patients with achalasia and no UES abnormalities, the majority (78.57%) had good treatment response, as compared to 21.43% with poor treatment response (P = 0.0001). After controlling for achalasia sub-type, those with UES abnormality had 26 times greater odds of poor treatment response than those with no UES abnormality (P = 0.009). Similarly, after controlling for treatment type, those with UES abnormality had 13.9 times greater odds of poor treatment response compared to those with no UES abnormality (P = 0.017).

CONCLUSION: The presence of UES abnormalities in patients with achalasia significantly predicted poorer treatment response as compared to those with normal UES function.

Endoscopic ultrasound as an adjunctive evaluation in patients with esophageal motor disorders subtyped by high-resolution manometry

BACKGROUND

Esophageal motor disorders are a heterogeneous group of conditions identified by esophageal manometry that lead to esophageal dysfunction. The aim of this study was to assess the clinical utility of endoscopic ultrasound (EUS) in the further evaluation of patients with esophageal motor disorders categorized using the updated Chicago Classification.

METHODS

We performed a retrospective, single center study of 62 patients with esophageal motor disorders categorized according to the Chicago Classification. All patients underwent standard radial endosonography to assess for extra-esophageal findings or alternative explanations for esophageal outflow obstruction. Secondary outcomes included esophageal wall thickness among the different patient subsets within the Chicago Classification.

KEY RESULTS

EUS identified 9/62 (15%) clinically relevant findings that altered patient management and explained the etiology of esophageal outflow obstruction. We further identified substantial variability in esophageal wall thickness in a proportion of patients including some with a significantly thickened non-muscular layer.

CONCLUSIONS & INFERENCES

EUS findings are clinically relevant in a significant number of patients with motor disorders and can alter clinical management. Variability in esophageal wall thickness of the muscularis propria and non-muscular layers identified by EUS may also explain the observed variability in response to standard therapies for achalasia.

Clinical characteristics and treatment outcomes of 3 subtypes of achalasia according to the chicago classification in a tertiary institute in Korea

Background/Aims

Achalasia is classified into 3 types according to the Chicago classification. The aim of this study was to investigate characteristics and treatment outcomes of 3 achalasia subtypes in Korean patients.

Methods

Fifty-five patients diagnosed with achalasia based on conventional or high-resolution esophageal manometry were consecutively enrolled. Their clinical characteristics, manometric, endoscopic and esophagographic findings and treatment responses were analyzed among the 3 subtypes of achalasia.

Results

Of 55 patients, 21 (38.2%) patients had type I, 28 (50.9%) patients had type II and 6 (10.9%) patients had type III. The median follow-up period was 22.4 (interquartile range, 3.6-67.4) months. Type III patients were older than type I and II patients (70.0 vs. 46.2 and 47.6 years, P = 0.023). The width of the esophagus in type I patients was wider with more frequent bird's beak appearance on esophagogram than the other 2 types (P = 0.010 and 0.006, respectively). Of the 50 patients who received the evaluation for treatment response at 3 months, 7 patients (36.8% vs. 26.9%) were treated with pneumatic dilatation and 4 patients (21.1% vs. 15.4%) with laparoscopic Heller's myotomy in type I and II groups, respectively. The treatment responses of pneumatic dilatation and Heller's myotomy in type I group were 71.4 and 50.0% and in type II were 85.7 and 75.0%, respectively, and all 5 patients in type III group showed good response to medical therapy.

Conclusions

Clinical characteristics of 3 achalasia subtypes in Korean patients are consistent with other studies. Treatment outcomes are variable among 3 subtypes.