Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram

Four-dimensional impedance manometry volume metrics for predicting abnormal bolus retention

BACKGROUND

The objective measurement for esophageal bolus volume and bolus clearance could classify abnormal high-resolution manometry (HRM) beyond the current Chicago classification. We aimed to compare the novel four-dimensional impedance manometry (4D HRM) volume metrics with timed barium esophagram (TBE).

METHODS

Adults with esophageal symptoms undergoing HRM and TBE were included. A custom-built program for 4D HRM analysis measured esophageal luminal cross-sectional area (CSA) from impedance and subsequently derived esophageal bolus volume and clearance. 4D HRM volume metrics included pre-swallow residual volume, maximal volume, retention volume, and clearance ratio defined as 1.0-retention volume divided by the maximal volume. An abnormal TBE was defined as a column height >5 cm at 1 min or 5 min.

KEY RESULTS

A total of 95 patients (normal motility: 33%; ineffective esophageal motility: 12%; absent contractility: 10%; esophagogastric junction outflow obstruction: 30%; type I achalasia: 5%; type II achalasia: 12%) were categorized into normal TBE (58%), abnormal TBE at 1 min (17%), and abnormal TBE at 5 min (25%). The AUROC demonstrated that, among all 4D HRM volume metrics, the clearance ratio had the best performance in predicting abnormal TBE at 5 min (AUROC, 95% confidence interval: 0.89, 0.82-0.96), and exhibited a strong negative correlation with TBE at 5 min (r = -0.65; p < 0.001).

CONCLUSIONS & INFERENCES

Novel 4D HRM volume metrics provide objective measurement of esophageal bolus volume and bolus clearance. The clearance ratio has a strong correlation with TBE and could potentially serve as a substitute for TBE to measure esophageal retention.

Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction

BACKGROUND

There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes.

METHODS

We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction.

KEY RESULTS

A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764).

CONCLUSIONS & INFERENCE

High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.

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.

The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram

BACKGROUND

Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function.

METHODS

Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model.

KEY RESULTS

Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78).

CONCLUSIONS AND INFERENCES

Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.

The American Broncho-Esophagological Association Position Statement on Swallowing Fluoroscopy

OBJECTIVES

To develop an expert consensus statement on the clinical use of swallowing fluoroscopy in adults that reduces practice variation and identifies opportunities for quality improvement in the care of patients suffering from swallowing impairment.

METHODOLOGY

A search strategist reviewed data sources (PubMed, Embase, Cochrane, Web of Science, Scopus) to use as evidence for an expert development group to compose statements focusing on areas of controversy regarding swallowing fluoroscopy. Candidate statements underwent two iterations of a modified Delphi protocol to reach consensus.

RESULTS

A total of 2184 publications were identified for title and abstract review with 211 publications meeting the criteria for full text review. Of these, 148 articles were included for review. An additional 116 publications were also included after reviewing the references of the full text publications from the initial search. These 264 references guided the authors to develop 41 candidate statements in various categories. Forty statements encompassing patient selection, fluoroscopic study choice, radiation safety, clinical team dynamics, training requirements, videofluoroscopic swallow study and esophagram techniques, and interpretation of swallowing fluoroscopy met criteria for consensus. One statement on esophagram technique reached near-consensus.

CONCLUSIONS

These 40 statements pertaining to the comprehensive use of swallowing fluoroscopy in adults can guide the development of best practices, improve quality and safety of care, and influence policy in both the outpatient and inpatient settings. The lack of consensus on some aspects of esophagram technique likely reflects gaps in knowledge and clinical practice variation and should be a target for future research. Laryngoscope, 133:255-268, 2023.

Rapid Drink Challenge During High-resolution Manometry for Evaluation of Esophageal Emptying in Treated Achalasia

BACKGROUND & AIMS

Incomplete esophageal emptying is a key variable predicting symptom relapse after achalasia treatment. Although optimally evaluated using the timed barium esophagogram (TBE), incomplete esophageal emptying can also be identified on rapid drink challenge (RDC) performed during high-resolution manometry.

METHODS

We evaluated if RDC differentiates complete from incomplete esophageal emptying in treated patients with achalasia, against a TBE gold standard. Unselected treated patients with achalasia with both TBE (200 mL of low-density barium suspension) and RDC (200 mL of water in sitting position) were enrolled in 5 tertiary referral centers. TBE barium column height at 1, 2, and 5 minutes were compared with RDC variables: pressurizations >20 mmHg, maximal RDC pressurization, proportion of RDC time occupied by pressurizations, trans-esophagogastric junction gradient, and integrated relaxation pressure.

RESULTS

Of 175 patients recruited (mean age, 59 years; 47% female), 138 (79%) were in clinical remission. Complete TBE emptying occurred in 45.1% at 1 minute, 64.0% at 2 minutes, and 73.1% at 5 minutes. RDC integrated relaxation pressure correlated strongly with TBE column height, and a 10-mmHg threshold discriminated complete from incomplete emptying at all 3 TBE time points with area under receiver operating characteristic curves of 0.85, 0.87, and 0.85, respectively. This threshold had high negative predictive values for complete emptying (88% at 2 minutes, 94% at 5 minutes), and modest positive predictive values for incomplete emptying (77% at 2 minutes, 62% at 5 minutes).

CONCLUSIONS

RDC during high-resolution manometry is an effective surrogate for TBE in assessing esophageal emptying in treated patients with achalasia.

Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation?

BACKGROUND

Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation.

MATERIALS AND METHODS

Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test.

RESULTS

At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters.

CONCLUSIONS

In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.

Comparison of functional lumen imaging probe and high-resolution manometry to assess response after peroral endoscopic myotomy

BACKGROUND AND AIMS

Outcomes after peroral endoscopic myotomy (POEM) are assessed clinically by the Eckardt score (ES) or objectively by high-resolution manometry (HRM) and functional lumen imaging probe (FLIP). This study compared HRM and FLIP to evaluate clinical response after POEM.

METHODS

This was a single tertiary center retrospective study of consecutive patients who underwent POEM for treatment-naive achalasia and with ≥6 months of follow-up. Baseline and follow-up testing in all patients included ES, HRM, and FLIP of the esophagogastric junction (EGJ). A normal post-POEM (or normalized) EGJ distensibility index (EGJ-DI) >2.8 mm²/mm Hg, maximum EGJ diameter (MxEGJD) ≥14 mm, and integrated relaxation pressure (IRP) <15 mm Hg were compared with a clinical response, defined as ES ≤3.

RESULTS

Eighty-seven patients (58% men, mean age 51 ± 17 years) were included. Overall clinical response by ES, IRP, MxEGJD, and EGJ-DI were 97.7%, 86.2%, 75.9%, and 92.0%, respectively. The sensitivity of a normal IRP (87.1% [95% confidence interval {CI}, 78.0-93.4]) was similar to the sensitivity of a normal MxEGJD (75.3% [95% CI, 64.7-84.0], P = .053) and normal EGJ-DI (91.8% [95% CI, 83.8%-96.6%], P = .39) after POEM to predict clinical response. However, the sensitivity of a normal post-POEM EGJ-DI was superior to a normal post-POEM MxEGJD (P = .001) to predict clinical response. There was no difference in the area under the curve of a normal MxEGJD or EGJ-DI to predict a normal IRP (P = .956) after POEM.

CONCLUSIONS

Normal FLIP metrics ≥6 months after POEM for achalasia show good to excellent sensitivity but are equivalent to a normalized IRP by HRM to predict clinical response by ESs. FLIP may be used as an alternative to HRM to assess lower esophageal sphincter response to POEM in these patients. (Clinical trial registration number: NCT02770859.).

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram

BACKGROUND

Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.

METHODS

A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.

RESULTS

AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).

CONCLUSIONS

Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.

Esophageal Motility Disorders: Are We Missing in Our Busy Endoscopy Practice?

Esophageal motility disorders (EMDs) form a significant part of a busy endoscopist's practice. Endoscopy plays an all-encompassing role in the diagnosis and management of EMDs including achalasia cardia. The focus on in-vogue third-space endoscopic procedures such as per-oral endoscopic myotomy often digresses the important role of endoscopy. Endoscopic evaluation forms the part of standard first-line evaluation of any dysphagia and serves to rule out a secondary cause such as an esophagogastric junction malignancy and eosinophilic esophagitis. Moreover, endoscopic evaluation may itself provide corroborative evidence that may contribute to the diagnosis of the motility disorder. Achalasia cardia may present with a wide spectrum of endoscopic findings from being entirely normal and the well-known and pathognomonic dilated sigmoid-shaped esophagus with food residue, to lesser-known ornate signs. The evidence on the role of endosonography in EMDs is conflicting and largely restricted to evaluation of pseudoachalasia. High-resolution manometry (HRM) remains the gold standard in the diagnosis of EMDs. Endoscopists must also keep abreast of the latest iteration of the Chicago classification version 4.0, which differs significantly from its predecessor in being more stringent in making diagnosis of esophagogastric junction outflow obstruction and disorders of peristalsis since these manometric findings may be seen in normal individuals and may be mimicked by opioid use and gastroesophageal reflux. The latest rendition also includes the use of provocative maneuvers and testing in both supine and sitting posture. Despite being the gold standard, there are certain lacunae in the use and interpretation of the Chicago classification of which the users should be well aware. Emerging technologies such as functional lumen imaging probe and planimetry, and timed barium esophagogram fill the lacuna in diagnosis of these motility disorders, which at times is beyond the resolution of HRM.

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 Role of Imaging Modalities in Diagnosing Dysphagia: A Clinical Review

Dysphagia, which is characterized by difficulty in oro-gastric bolus transit, is a common condition. It is broadly classified into oropharyngeal or esophageal pathology. A wide array of differentials for dysphagia and initial clinical suspicion of oropharyngeal or esophagus etiology can assist in further evaluation. Fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallow study (VFSS) are the preferred modalities for assessing oropharyngeal bolus transit, residual, as well as determining the risk of laryngeal aspiration. High-resolution pharyngeal manometry (HRPM) is an emerging modality for optimal topographical and pressure assessment of pharyngeal anatomy. HRPM provides improved assistance in evaluating the strength of the pharyngeal muscular contraction. Esophagogastroduodenoscopy (EGD) is the preferred exam for patients with suspected esophageal etiology of dysphagia. Barium swallow provides luminal assessment and assists in evaluating esophageal motility; it is non-invasive, but therapeutic interventions like biopsy cannot be performed. High-resolution esophageal manometry (HREM) has added another dimension in the diagnosis of esophageal motility disorders. The purpose of this review article is to help internists and primary care providers get a better understanding of the role of various imaging modalities in diagnosing dysphagia in the elderly population. This article also provides a comprehensive review and detailed comparison of these imaging modalities based on the latest evidence.

Advances and caveats in modern achalasia management

Achalasia is a rare esophageal motility disorder characterized by the incomplete relaxation of the lower esophageal sphincter (LES) and impaired peristaltic activity. The advent of high-resolution manometry (HRM) and the rapidly evolving role of therapeutic endoscopy have revolutionized the approach to the diagnosis and management of achalasia patients in the last decade. With advances in HRM technology and methodology, fluoroscopy and EndoFlip, achalasia can be differentiated into therapeutically meaningful phenotypes with a high degree of accuracy. Further, the newest treatment option, per-oral endoscopic myotomy (POEM), has become a staple therapy following the last 10 years of experience, and recent randomized trials appear to show no difference between POEM, graded pneumatic dilatation and surgical Heller myotomy in terms of short- and long-term efficacy or complication rate. On the other hand, how treatment outcomes are measured as well as the risk of reflux following therapy remain areas of contention. This review aims to summarize the recent advancements in achalasia testing and therapy, describes the recent randomized clinical trials as well as their potential setbacks, and touches on the future of personalizing achalasia treatment.

Timed barium swallow for assessing long-term treatment response in patients with achalasia: Absolute cutoff versus percent change - A cross-sectional analytic study

BACKGROUND

Timed barium swallow (TBS) assesses esophageal emptying before and after therapy in patients with achalasia. Our aim was to compare the accuracy of percent change in barium height with traditional absolute cutoff of <5 cm on post-treatment TBS.

MATERIALS AND METHODS

Consecutive patients with treatment naïve achalasia treated with either PD, HM, or POEM between 1/2012 and 7/2017 were eligible for inclusion. The accuracy of percent change in pre- and post-treatment barium height at 5 minutes versus an absolute <5 cm cutoff for assessing treatment response was assessed using the receiver operating curve analysis (ROC).

RESULTS

Eighty-one patients met the inclusion criteria. The median percent change in barium heights at five minutes in patients who did not improve was 6 percent increase (n = 10; mean 10.6) versus 78 percent decrease (n = 71; mean 64) in patients who improved (P = 0.0001). The AUC for percent change in TBS 5 minutes height was 76% (95% CI 48% to 90%), and a 3% decrease from baseline as a cutoff had a sensitivity of 60% and specificity of 99%. The AUC for post-treatment TBS 5 minutes height was 79% (95% CI 53% to 91%), and the 5 cm cutoff had a sensitivity of 70% and specificity of 75%.

CONCLUSIONS

The results show that 3% percent improvement in pre- and post-treatment barium height at 5 minutes rather than absolute cutoff value of <5 cm on post-treatment TBS is a better indicator of treatment success in achalasia patients. These findings indicate the need for reassessment of tools to identify treatment response.

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.

Achalasia: physiology and diagnosis

Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.

Updates on diagnostic modalities for esophageal dysphagia

Esophageal dysphagia is a common symptom in adults. Fluoroscopic contrast studies, endoscopy, and esophageal manometry have been used in the diagnosis of esophageal dysphagia for many years. The diagnostic yield has been improved with new test protocols that highlight abnormal bolus transit in the esophagus and outflow obstruction, as well as new high-definition and high-resolution technical advances in equipment. Functional luminal impedance planimetry and the addition of impedance to high-resolution esophageal manometry have also allowed the assessment of new parameters to better understand esophageal structure and function. In this concise review, we describe the role and utility of various diagnostic modalities in the assessment of patients with esophageal dysphagia.

ACG Clinical Guidelines: Diagnosis and Management of Achalasia

Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.

Factors Associated With Achalasia Treatment Outcomes: Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Identification of factors associated with achalasia treatment outcome might help physicians select therapies based on patient characteristics. We performed a systematic review and meta-analysis to identify factors associated with treatment response.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library through February 21, 2019, for randomized controlled trials and cohort, case-control, and cross-sectional studies that reported patient-specific outcomes of treatment (botulinum toxin injection, pneumatic dilation, peroral endoscopic myotomy, or laparoscopic Heller myotomy). We assessed the methodologic quality of the included studies using the quality in prognosis studies tool. We planned qualitative and quantitative analyses.

RESULTS

We analyzed data from 75 studies (8 randomized controlled trials, 27 prospective cohort studies, and 40 retrospective studies) on a total of 34 different factors associated with outcomes (3 demographic, 17 clinical, and 14 diagnostic factors). Qualitative assessment showed age, manometric subtype, and presence of a sigmoid-shaped esophagus as factors associated with outcomes of treatment for achalasia with a strong level of evidence. The cumulative evidence for the association with chest pain, symptom severity, and lower esophageal sphincter pressure was inconclusive. A meta-analysis confirmed that older age (mean difference, 7.9 y; 95% CI, 1.5-14.3 y) and manometric subtype 3 (odds ratio, 7.1; 95% CI, 4.1-12.4) were associated with clinical response.

CONCLUSIONS

In a systematic review and meta-analysis, we found age and manometric subtype to be associated with outcomes of treatment for achalasia. This information should be used to guide treatment decisions.

Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy

BACKGROUND

Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population.

METHODS

All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively.

DATA COLLECTED

demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes.

RESULTS

A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance.

CONCLUSION

There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

BACKGROUND

Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence.

METHODS

Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures.

RESULTS

One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances.

CONCLUSIONS

Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

Esophageal Dysphagia in the Elderly

PURPOSE OF REVIEW

With a globally aging population, dysphagia is a growing health concern among elderly. Increasing reflux disease has contributed to an increased prevalence of dysphagia from peptic strictures and esophageal cancer. Dysphagia can lead to malnutrition and aspiration pneumonia, causing considerable morbidity and mortality. This review article focuses on recent advances in the approach and management of esophageal dysphagia.

RECENT FINDINGS

Endoscopic functional luminal imaging probe is a novel test that complements upper endoscopy, esophagram, and esophageal manometry for evaluation of esophageal dysphagia. Opioid induced esophageal dysfunction (OIED) is an emerging clinical entity that can mimic achalasia. Strictures refractory to dilation can be treated with intralesional steroid injections, electrosurgical incision, or esophageal stents. Peroral endoscopic myotomy (POEM) is gaining in popularity for treatment of achalasia and other spastic disorders of esophagus. Treatment of esophageal dysphagia may include proton pump inhibitors, endoscopic dilation, or surgery and requires a personalized approach based on risks and benefits. POEM is a valuable therapy for achalasia, but further studies are needed to evaluate its use, and other alternatives, for treatment of OIED and spastic esophageal disorders.

Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia-Anatomy Matters!

INTRODUCTION

To compare the utility of the distensibility index (DI) on functional lumen imaging probe (FLIP) topography to other esophagogastric junction (EGJ) metrics in assessing treatment response in achalasia in the context of esophageal anatomy.

METHODS

We prospectively evaluated 79 patients (at ages 17-81 years; 47% female patients) with achalasia during follow-up after pneumatic dilation, Heller myotomy, or per-oral endoscopic myotomy with timed barium esophagram, high-resolution impedance manometry, and FLIP. Anatomic deformities were identified based on consensus expert opinion. Patients were classified based on anatomy and EGJ opening to determine the association with radiographic outcome and Eckardt score (ES).

RESULTS

Twenty-seven patients (34.1%) had an anatomic deformity-10 pseudodiverticula at myotomy, 7 epiphrenic diverticula, 5 sigmoid, and 5 sinktrap. A 5-minute column area of >5 cm was best associated with an ES of >3, with a sensitivity of 84% (P = 0.0013). Area under the curve for EGJ metrics in association with retention was as follows: DI, 0.90; maximal EGJ diameter, 0.76; integrated relaxation pressure, 0.64; and basal esophagogastric junction pressure, 0.53. Only FLIP metrics were associated with retention given normal anatomy (DI 2.4 vs 5.2 mm/mm Hg and maximal EGJ diameter 13.1 vs 16.6 mm in patients with and without retention, respectively; P values < 0.0001 and 0.002). Using a DI cutoff of <2.8 as abnormal, 40 of 45 patients with retention (P = 0.0001) and 23 of 25 patients with an ES of >3 (P = 0.02) had a low DI and/or anatomic deformity. With normal anatomy, 21 of 22 patients with retention had a low or borderline low DI.

DISCUSSION

The FLIP DI is most useful metric for assessing the effect of achalasia treatment on EGJ opening. However, abnormal anatomy is an important mediator of outcome and treatment success will be modulated by anatomic defects that impede bolus emptying.

Pneumatic dilation improves esophageal emptying and symptoms in patients with idiopathic esophago-gastric junction outflow obstruction

BACKGROUND AND AIMS

Idiopathic Esophago-gastric outflow obstruction (EGJOO) is a new clinical entity resulting in delayed esophageal emptying secondary to a poorly relaxing lower esophageal sphincter. Little is known about treatment outcomes of idiopathic EGJOO patients. The aim of this study was to investigate the clinical response of pneumatic dilation (PD) in idiopathic EGJOO patients with a standing barium column and/or with pill arrest on timed barium esophagram (TBE) before and after undergoing PD.

METHODS

Idiopathic EGJOO patients with retained liquid barium on TBE at 1 minute and/or with pill arrest in esophagus at 5 minutes were included. Patients were treated with PD and evaluated with post-procedural TBE.

RESULTS

A total of 33 patients with Idiopathic EGJOO and poor esophageal emptying on TBE were treated with PD. 67% of Idiopathic EGJOO patients reported subjective symptom relief, 18% improved and symptoms later recurred, 6% were lost to follow up, and 9% reported no change. TBE results of pre-PD showed 1 minute average barium column height of 11.0 cm and 1 minute barium column width of 1.7 cm. There was significant decrease in 1 minute liquid barium column height and width (P < 0.001 and <0.001, respectively) as well as significant improvement in pill passing (P < 0.006) after undergoing PD. No complications occurred after PD.

CONCLUSION

PD is an effective initial treatment for Idiopathic EGJOO patients with abnormal TBE. Pneumatic dilation relieved symptoms and improved esophageal emptying in Idiopathic EGJOO patients on TBE.

Angle of His Accentuation Is a Viable Alternative to Dor Fundoplication as an Adjunct to Laparoscopic Heller Cardiomyotomy: Results of a Randomized Clinical Study

BACKGROUND

There is no consensus regarding the type of anti-reflux procedure to be used as an adjunct to laparoscopic Heller cardiomyotomy (LHCM). The aim of this study was to compare Angle of His accentuation (AOH) with Dor Fundoplication (Dor) as an adjunct to LHCM.

METHODS

A total of 110 patients with achalasia cardia presenting for LHCM from March 2010 to July 2015 were randomized to Dor and AOH. Symptom severity, achalasia-specific quality of life (ASQOL), new onset heartburn, and patient satisfaction were assessed using standardized scores preoperatively, at 3, 6 months, and then yearly. The primary outcome was relief of esophageal symptoms while secondary outcomes were new onset heartburn and ASQOL.

RESULTS

Both groups were comparable with respect to the baseline demographic characteristics. There was no conversion to open and no mortality in either group. Median operative time was 128 min in AOH and 144 min in Dor group (p < 0.01). Mean follow-up was 36 months and was available in 98% patients. There was significant improvement in esophageal symptoms in both groups with no statistically significant difference between the two groups (p > 0.05). There was no difference in cumulative symptom scores between the two groups over the period of follow-up. New onset heartburn was seen in 11% in AOH and 9% in Dor group. Mean ASQOL score improved in both groups with no difference between the two groups (p = 0.83). Patient satisfaction was similar in both groups.

CONCLUSION

AOH is similar to Dor as an adjunct to LHCM in safety and efficacy and can be performed in shorter time.

CLINICAL REGISTRATION NUMBER

CTRI: REF/2014/06/007146.

Results of pneumatic dilation in treating achalasia: predictive factors

Forced pneumatic dilatation (PD) of the cardia is one of the most consecrated therapeutic measures for esophageal achalasia. The procedure only achieved better standardization with the appearance of the Rigiflex balloon. Results and predictive factors of success and failure of PD are reviewed, right after the description of the main technical aspects of the procedure. The success rates, providing control of dysphagia for about 1 year from the procedure using the Rigiflex balloon, are quite satisfactory, with success in more than 75% of patients. It is generally observed that good responses sustained for more than 5 years appear in at least 40% of cases. However, approximately half of the patients submitted to PD require additional dilation and a subgroup of them will undergo surgical treatment to attain adequate control of dysphagia. PD is a method with a low rate of acute complications, with esophageal perforation, the most severe of them, not affecting more than 5% of the cases. The best results could be potentially obtained when predictive factors of success were considered before choosing PD as a therapeutic option, but prospective studies in this field are missing until now.

Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry

BACKGROUND & AIMS

Esophageal retention is typically evaluated by timed-barium esophagram in patients treated for achalasia. Esophageal bolus clearance can also be evaluated using high-resolution impedance manometry. We evaluated the associations of conventional and novel high-resolution impedance manometry metrics, esophagram, and patient-reported outcomes (PROs) in achalasia.

METHODS

We performed a prospective study of 70 patients with achalasia (age, 20-81 y; 30 women) treated by pneumatic dilation or myotomy who underwent follow-up evaluations from April 2013 through December 2015 (median, 12 mo after treatment; range, 3-183 mo). Patients were assessed using timed-barium esophagrams, high-resolution impedance manometry, and PROs, determined from Eckardt scores (the primary outcome) and the brief esophageal dysphagia questionnaire. Barium column height was measured from esophagrams taken 5 minutes after ingestion of barium (200 mL). Impedance-manometry was analyzed for bolus transit (dichotomized) and with a customized MATLAB program (The MathWorks, Inc, Natick, MA) to calculate the esophageal impedance integral (EII) ratio.

RESULTS

Optimal cut points to identify a good PRO (defined as Eckardt score of ≤3) were esophagram barium column height of 3 cm (identified patients with a good PRO with 63% sensitivity and 75% specificity) and an EII ratio of 0.41 (identified patients with a good PRO with 83% sensitivity and 75% specificity). Complete bolus transit identified patients with a good PRO with 28% sensitivity and 75% specificity. Of the 25 patients who met these cut points for both esophagram barium column height and EII ratio, 23 (92%) had a good PRO. Of the 17 patients who met neither cut point, 14 (82%) had a poor PRO (Eckardt score above 3).

CONCLUSIONS

In a prospective study of 70 patients with achalasia, we found EII ratio identified patients with good PROs with higher levels of sensitivity (same specificity) than timed-barium esophagram or impedance-manometry bolus transit assessments. The EII ratio should be added to achalasia outcome evaluations that involve high-resolution impedance manometry as an independent measure and to complement timed-barium esophagram.

Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia

BACKGROUND AND AIMS

Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia.

METHODS

A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group.

RESULTS

The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry.

CONCLUSIONS

Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.

Peroral endoscopic myotomy for the treatment of achalasia and other esophageal motor disorders: Short-term and medium-term results at a Mexican tertiary care center

INTRODUCTION AND AIMS

Achalasia is characterized by the absence of lower esophageal sphincter relaxation and esophageal aperistalsis. Diagnosis is confirmed through high-resolution esophageal manometry. Laparoscopic myotomy is the standard treatment, but peroral endoscopic myotomy (POEM) is a safe and effective alternative, with good short-term and medium-term results. Our aim was to describe the short-term and medium-term experience with POEM at a tertiary care center.

MATERIALS AND METHODS

The study was conducted within the time frame of November 2014 and February 2017. Treatment-naïve achalasia patients and previously-treated achalasia patients that were candidates for POEM were included. A protocolized 24-month follow-up was carried out.

RESULTS

Fifty procedures were included and 31 (68%) were performed on women. Forty-one (82%) of the procedures were carried out on previously untreated patients, 7 (14%) were performed on previously treated patients, and 2 (4%) of the patients had redo-POEM. The mean age of the patients was 48.8±14.1 years. The pre-POEM Eckardt score was 9 and the integrated relaxation pressure was 24.4mmHg. Sixty-eight percent of the patients had type ii achalasia. Procedure time was 80min and myotomy length was 12.6cm. Hospital stay was 3 days and subcutaneous emphysema was the most common adverse event (30%). A total of 22/50 (44%) patients reached the 24-month follow-up, maintaining the Eckardt score and the decrease in the integrated relaxation pressure. There were no deaths. A total of 47.5% of the patients had a positive pH-study at 6 months, 15% had clinical reflux, and 35% presented with mild esophagitis. All the patients were adequately controlled with proton pump inhibitors.

CONCLUSION

POEM is safe and effective in the short term and medium term for the treatment of achalasia and other esophageal motor disorders in Mexican patients.

Timed Barium Swallow: Diagnostic Role and Predictive Value in Untreated Achalasia, Esophagogastric Junction Outflow Obstruction, and Non-Achalasia Dysphagia

OBJECTIVES

Timed barium swallow (TBS) assesses esophageal emptying in patients with achalasia and is considered the standard workup for patients with dysphagia. Our aim was to determine the usefulness of TBS in differentiating patients with achalasia (type 1-3), esophagogastric junction outflow obstruction (EGJOO), and non-achalasia dysphagia.

METHODS

We performed a retrospective cohort study including consecutive patients who underwent TBS evaluation between May 2013 and September 2015. Patients were separated into untreated achalasia (n=117), EGJOO (n=46), and non-achalasia (n=146) groups. Diagnosis of achalasia/EGJOO was based on high-resolution manometry using Chicago Classification. Receiver operating characteristic (ROC) curve analysis was performed to determine the accuracy of TBS (barium height at 1 and 5 min and tablet retention) in identifying achalasia vs. EGJOO and non-achalasia.

RESULTS

Barium column height of 5 cm at 1 min showed a sensitivity of 94% and specificity of 71% and barium column height of 2 cm at 5 min showed a sensitivity of 85% and specificity of 86% in differentiating untreated achalasia from EGJOO and non-achalasia. Combined liquid barium and tablet increases diagnostic yield from 79.5 to 100% in untreated achalasia patients and from 48.9 to 60% in EGJOO patients.

CONCLUSIONS

TBS is a simple and useful test in differentiating untreated achalasia, EGJOO, and non-achalasia dysphagia. We propose that barium height >2 cm at 5 min be used as cutoff point for identifying achalasia. Combination of liquid barium and tablet increased the diagnostic yield of TBS in achalasia and EGJOO. Retention of barium tablet alone suggests functional/anatomic obstruction at the esophagogastric junction.

Esophageal stasis in achalasia patients without symptoms after treatment does not predict symptom recurrence

BACKGROUND

After achalasia treatment, a subset of patients has poor esophageal emptying without having symptoms. There is no consensus on whether to pre-emptively treat these patients. We hypothesized that, if left untreated, these patients will experience earlier symptom recurrence than patients without stasis.

METHODS

99 treated achalasia patients who were in clinical remission (Eckardt ≤3) at 3 months after treatment were divided into two groups, based on presence or absence of esophageal stasis on a timed barium esophagogram performed after 3 months.

KEY RESULTS

Two years after initial treatment, patients with stasis after treatment still had a wider esophagus (3 cm; IQR: 2.2-3.8) and more stasis (3.5 cm; IQR: 1.9-5.6) than patients without stasis (1.8 cm wide and 0 cm stasis; both P<.001). In patients with stasis, the esophageal diameter had increased from 2.5 to 3.0 cm within 2 years of follow-up. The symptoms, need for and time to retreatment were comparable between the two groups. Quality of life and reflux symptoms were also comparable between the two groups.

CONCLUSIONS & INFERENCES

Although patients with stasis initially had a wider esophagus and 2 years after treatment also had a higher degree of stasis and a more dilated esophagus, compared to patients without stasis, they did not have a higher chance of requiring retreatment. We conclude that stasis in symptom-free achalasia patients after treatment does not predict treatment failure within 2 years and can therefore not serve as a sole reason for retreatment.

High-Resolution Impedance Manometry Metrics of the Esophagogastric Junction for the Assessment of Treatment Response in Achalasia

OBJECTIVES

We aimed to evaluate the value of novel high-resolution impedance manometry (HRIM) metrics, bolus flow time (BFT), and esophagogastric junction (EGJ) contractile integral (CI), as well as EGJ pressure (EGJP) and the integrated relaxation pressure (IRP), as indicators of treatment response in achalasia.

METHODS

We prospectively evaluated 75 patients (ages 19-81, 32 female) with achalasia during follow-up after pneumatic dilation or myotomy with Eckardt score (ES), timed-barium esophagram (TBE), and HRIM. Receiver-operating characteristic (ROC) curves for good symptomatic outcome (ES≤3) and good radiographic outcome (TBE column height at 5 min<5 cm) were generated for each potential predictor of treatment response (EGJP, IRP, BFT, and EGJ-CI).

RESULTS

Follow-up occurred at a median (range) 12 (3-291) months following treatment. A total of 49 patients had good symptomatic outcome and 46 had good radiographic outcome. The area-under-the-curves (AUCs) on the ROC curve for symptomatic outcome were 0.55 (EGJP), 0.62 (IRP), 0.77 (BFT) and 0.56 (EGJ-CI). The AUCs for radiographic outcome were 0.64 (EGJP), 0.48 (IRP), 0.73 (BFT), and 0.65 (EGJ-CI). Optimal cut-points were determined as 11 mm Hg (EGJP), 12 mm Hg (IRP), 0 s (BFT), and 30 mm Hg•cm (EGJ-CI) that provided sensitivities/specificities of 57%/46% (EGJP), 65%/58% (IRP), 78%/77% (BFT), and 53%/62% (EGJ-CI) to predict symptomatic outcome and 57%/66% (EGJP), 57%/41% (IRP), 76%/69% (BFT), and 57%/66% (EGJ-CI) to predict radiographic outcome.

CONCLUSIONS

BFT, a novel HRIM metric, provided an improved functional assessment over manometric measures of EGJP, IRP, and EGJ-CI at follow-up after achalasia treatment and may help direct clinical management.

Management of achalasia in the UK, do we need new guidelines?

Aim

It is recommended that management of complex benign upper gastrointestinal pathology is discussed at multi disciplinary team (MDT) meetings. American College of Gastroenterology (ACG) guidelines further recommend that treatment delivery is provided by high volume centres, with objective post-procedural investigations, in order to improve patient outcomes. We aimed to survey the current UK practice in the management of achalasia.

Methods

443 Upper gastrointestinal (UGI) specialist surgeons throughout the UK were sent a surveymonkey.com questionnaire about the management of achalasia.

Results

100 responses were received. The majority of patients with achalasia are referred directly to surgeons (80%) and only 15% of units have a MDT meeting for discussing such patients. Diagnosis was mainly with oesophagogastroduodenoscopy (OGD) and contrast swallow, and only 61% of units have access to high resolution manometry (HRM). 89% of younger patients were offered surgery initially, whilst in the elderly surgery was offered as first line treatment in 55%. Partial fundoplication was carried out by 91% of responders as part of the operation, and 58% responders carry out an intraoperative OGD. The average number of operations carried out per annum is 4 per responder. Most responders (66%) did not perform routine post-intervention investigations and follow-up varied from none to lifelong.

Conclusion

Diagnosis and management of achalasia within the UK is relatively standardised, although there remains limited access to HRM. Discussion at benign MDTs however is poor and follow-up differs widely. UK guidelines may help to make these more uniform.

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Questionnaire to UK Upper GI specialists on achalasia management.

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No current UK guidelines.

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NICE guidelines refer to 2011 SAGES guidelines.

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Only 15% have benign MDT to discuss complex achalasia cases.

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Disparities in management with deviations from current US guidelines.

Achalasia-Specific Quality of Life After Pneumatic Dilation or Laparoscopic Heller Myotomy With Partial Fundoplication: A Multicenter, Randomized Clinical Trial

OBJECTIVES

Achalasia is a chronic, progressive, and incurable esophageal motility disease. There is clinical uncertainty about which treatment should be recommended as first-line therapy. Our objective was to evaluate the effectiveness of pneumatic dilation compared with laparoscopic Heller myotomy with partial fundoplication in improving achalasia-specific quality of life.

METHODS

This was a prospective, multicenter, randomized trial at five academic hospitals in Canada. Fifty previously untreated adults with a clinical diagnosis of primary achalasia, confirmed by manometric testing, were enrolled between November 2005 and March 2010, and followed for 5 years after treatment. Randomization was stratified by site, in random blocks of size four and with balanced allocation. Patients were treated with pneumatic dilation or laparoscopic Heller myotomy with partial fundoplication. The primary outcome was the difference between the treatments in the mean improvement of the achalasia severity questionnaire (ASQ) score at 1 year from baseline. Prespecified secondary outcomes included general and gastrointestinal quality of life, symptoms, esophageal physiology measures (lower esophageal sphincter relaxation and pressure, esophageal emptying, abnormal esophageal acid exposure), complications, and incidence of retreatment. Functional and imaging studies were performed blinded and all outcome assessors were blinded.

RESULTS

There were no significant differences between treatments in the improvement of ASQ score at 1 year from baseline (27.5 points in the Heller myotomy arm vs. 20.2 points in the pneumatic dilation arm; difference 7.3 points, 95% confidence interval -4.7 to 19.3; P=0.23). There were no differences between treatments in improvement of symptoms, general and gastrointestinal quality of life, or measures of esophageal physiology. Improvements in ASQ score diminished over time for both interventions. At 5 years, there were no differences between treatments in improvement of ASQ score, symptoms, and general or gastrointestinal quality of life. There were no serious adverse events. No patient who received Heller myotomy required retreatment, whereas five patients treated initially with pneumatic dilation required retreatment.

CONCLUSIONS

Treatment with pneumatic dilation or laparoscopic Heller myotomy similarly improves achalasia-specific disease severity at 1 year. Either of the therapeutic approaches can be used as first-line therapy for previously untreated adults with achalasia.

Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms

The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting the HRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.

Clinical management of achalasia: current state of the art

Achalasia is a primary disorder of esophageal motility. It classically presents with dysphagia to both solids and liquids but may be accompanied by regurgitation and chest pain. The gold standard for the diagnosis of achalasia is esophageal motility testing with manometry, which often reveals aperistalsis of the esophageal body and incomplete lower esophageal sphincter relaxation. The diagnosis is aided by complimentary tests, such as esophagogastroduodenoscopy and contrast radiography. Esophagogastroduodenoscopy is indicated to rule out mimickers of the disease known as “pseudoachalasia” (eg, malignancy). Endoscopic appearance of a dilated esophagus with retained food or saliva and a puckered lower esophageal sphincter should raise suspicion for achalasia. Additionally, barium esophagography may reveal a dilated esophagus with a distal tapering giving it a “bird’s beak” appearance. Multiple therapeutic modalities aid in the management of achalasia, the decision of which depends on operative risk factors. Conventional treatments include medical therapy, botulinum toxin injection, pneumatic dilation, and Heller myotomy. The last two are defined as the most definitive treatment options. New emerging therapies include peroral endoscopic myotomy, placement of self-expanding metallic stents, and endoscopic sclerotherapy.

Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM)

BACKGROUND

Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM.

METHODS

POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine contrast esophagram was obtained on POD #1. We conducted a retrospective review of the radiologists' interpretations of these studies and compared them to patient's clinical course.

RESULTS

Seventy-eight patients were included. Among these, two complications occurred. One patient was non-compliant with postoperative nil per os orders and developed epigastric pain suspicious for a leak that was demonstrated on esophagram. Another patient had subcutaneous emphysema on POD #1 esophagram, a finding that was also present on physical examination, without esophageal leakage. Another esophagram in an asymptomatic patient was suspicious for submucosal tunnel hematoma which prompted a return to the operating room with negative results. Overall, 56 patients had abnormal studies. POD #1 esophagram demonstrated a sensitivity of 100 % and specificity of 45 % in identifying clinically significant complications.

CONCLUSIONS

In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

Idiopathic (primary) achalasia: a review

Idiopathic achalasia is a primary esophageal motor disorder characterized by loss of esophageal peristalsis and insufficient lower esophageal sphincter relaxation in response to deglutition. Patients with achalasia commonly complain of dysphagia to solids and liquids, bland regurgitation often unresponsive to an adequate trial of proton pump inhibitor, and chest pain. Weight loss is present in many, but not all patients. Although the precise etiology is unknown, it is often thought to be either autoimmune, viral immune, or neurodegenerative. The diagnosis is based on history of the disease, barium esophagogram, and esophageal motility testing. Endoscopic assessment of the gastroesophageal junction and gastric cardia is necessary to rule out malignancy. Newer diagnostic modalities such as high resolution manometry help in predicting treatment response in achalasia based on esophageal pressure topography patterns identifying three phenotypes of achalasia (I-III) and outcome studies suggest better treatment response with types I and II compared to type III. Although achalasia cannot be permanently cured, excellent outcomes are achieved in over 90 % of patients. Current medical and surgical therapeutic options (pneumatic dilation, endoscopic and surgical myotomy, and pharmacologic agents) aim at reducing the LES pressure and facilitating esophageal emptying by gravity and hydrostatic pressure of retained food and liquids. Either graded pneumatic dilatation or laparoscopic surgical myotomy with a partial fundoplication are recommended as initial therapy guided by patient age, gender, preference, and local institutional expertise. The prognosis in achalasia patients is excellent. Most patients who are appropriately treated have a normal life expectancy but the disease does recur and the patient may need intermittent treatment.

Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes

BACKGROUND

In the recently reported international survey of centers performing per-oral endoscopic myotomy (POEM), 88% of operators reported obtaining routinely an early postoperative contrast esophagram. To date, there have been no studies to assess the prognostic value of early esophagram in POEM.

METHODS

A retrospective review of a prospectively maintained, single-institution database of patients who underwent POEM for treatment of achalasia was conducted. Patients were evaluated with a routine contrast esophagram on the first postoperative day (POD#1) to assess for perforation. The finding of delayed esophageal emptying, as determined by an attending radiologist, was compared with the patients' symptomatic outcomes and functional parameters at one year follow-up.

RESULTS

Contrast esophagram was obtained on POD#1 for 72 patients undergoing POEM; 26 patients (36%) were observed to have a delay in esophageal emptying. Both groups of patients, those with a delay and those without a delay in esophageal emptying on POD#1, had similar preoperative Eckardt scores (7 ± 2 vs 7 ± 2, P = ns) and column height at 5 minutes on preoperative timed barium esophagram (12.1 ± 8 cm vs 14.1 ± 8 cm, P = ns). At a mean follow-up of 1 year, there was no difference in Eckardt scores between patients with and those without a delay in emptying on POD#1 esophagram (1 ± 2 vs 1 ± 1, P = ns), nor was there a difference between the 2 groups in column height at 5 minutes on TBE (5.5 ± 5 cm for delay vs 4.2 ± 4 cm for no delay; P = ns). Rates of treatment failure, as measured by Eckardt score >3 or need for subsequent treatment, also did not differ between the 2 groups (3 patients with delay vs 4 patients without delay in emptying, P = ns).

CONCLUSION

Delay in passage of contrast on POD#1 esophagram did not predict symptomatic or physiologic outcomes at 1-year follow-up in patients undergoing POEM for treatment of achalasia.

The Pathogenesis and Management of Achalasia: Current Status and Future Directions

Achalasia is an esophageal motility disorder that is commonly misdiagnosed initially as gastroesophageal reflux disease. Patients with achalasia often complain of dysphagia with solids and liquids but may focus on regurgitation as the primary symptom, leading to initial misdiagnosis. Diagnostic tests for achalasia include esophageal motility testing, esophagogastroduodenoscopy and barium swallow. These tests play a complimentary role in establishing the diagnosis of suspected achalasia. High-resolution manometry has now identified three subtypes of achalasia, with therapeutic implications. Pneumatic dilation and surgical myotomy are the only definitive treatment options for patients with achalasia who can undergo surgery. Botulinum toxin injection into the lower esophageal sphincter should be reserved for those who cannot undergo definitive therapy. Close follow-up is paramount because many patients will have a recurrence of symptoms and require repeat treatment.

Oesophageal dysphagia: manifestations and diagnosis

Oesophageal dysphagia is a common symptom, which might be related to severe oesophageal diseases such as carcinomas. Therefore, an organic process must be ruled out in the first instance by endoscopy in all patients presenting with dysphagia symptoms. The most prevalent obstructive aetiologies are oesophageal cancer, peptic strictures and eosinophilic oesophagitis. Eosinophilic oesophagitis is one of the most common causes of dysphagia in adults and children, thus justifying the need to obtain oesophageal biopsy samples from all patients presenting with unexplained dysphagia. With the advent of standardized high-resolution manometry and specific metrics to characterize oesophageal motility, the Chicago classification has become a gold-standard algorithm for manometric diagnosis of oesophageal motor disorders. In addition, sophisticated investigations and analysis methods that combine pressure and impedance measurement are currently in development. In the future, these techniques might be able to detect subtle pressure abnormalities during bolus transport, which could further explain pathophysiology and symptoms. The degree to which novel approaches will help distinguish dysphagia caused by motor abnormalities from functional dysphagia still needs to be determined.

Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy?

OBJECTIVE

Per-oral endoscopic myotomy (POEM) has recently been introduced as a minimal invasive alternative to conventional treatment for achalasia. This study aimed to clarify the feasibility and the short-term clinical efficacy of POEM as compared to laparoscopic Heller myotomy (LHM).

METHODS

Treatment outcomes were prospectively recorded and compared between the procedures in a nonrandomized fashion. Reduction rate (RR) in timed barium esophagogram (TBE) was calculated at 1, 2 and 5 min after barium ingestion as: RR = 1- postoperative barium height/preoperative barium height. Risk factors for treatment failure defined as the proportion of patients with RR <0.5 (1 min) and gastroesophageal reflux (GER) after POEM were analyzed.

RESULTS

Forty-two consecutive patients who underwent POEM were compared to 41 patients who had a LHM during the immediate time period prior to the introduction of POEM. Ninety percent of the cases reported complete symptom relief after POEM. The percentage of esophageal emptying and RR in TBE improved dramatically by both procedures without significant difference. A longer operation time (odds ratio [OR] 32.80, 95%CI 2.99-359.82, p = 0.004) and younger age (OR 26.81, 95%CI 2.09-344.03, p = 0.012) were the independent predictors of treatment failure after POEM. GER was observed in seven patients where previous dilatation (OR 8.59, 95%CI 1.16-63.45, p = 0.035) and higher body mass index (OR 8.69, 95%CI 1.13-66.63, p = 0.037) were the independent predictors for symptomatic GER after POEM.

CONCLUSION

POEM seems to be a safe and effective treatment option for achalasia in the short-term perspective; an effect well comparable to LHM.

Clinical application of endoscopic ultrasonography for esophageal achalasia

Endoscopic ultrasonography (EUS) has been widely used for evaluating the nature of diseases of various organs. The possibility of applying EUS for esophageal motility diseases has not been well discussed despite its versatility. At present, peroral endoscopic myotomy (POEM) for esophageal achalasia and related diseases has brought new attention to esophageal diseases because POEM provides a more direct approach to the inner structures of the esophageal wall. In the present study, we discuss the clinical utility of EUS in evaluating and treating esophageal motility diseases such as esophageal achalasia and related diseases.

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.