ACG Clinical Guidelines: Diagnosis and Management of Achalasia

Imaging following endoscopic and surgical treatment of achalasia

Achalasia is an esophageal motility disorder characterized by absent esophageal peristalsis associated with failure of relaxation of the lower esophageal sphincter (LES). Patients with achalasia may present with long-standing and slowly progressive dysphagia to solids and liquids, heartburn, regurgitation, refractory reflux symptoms and noncardiac chest pain. The esophagram and the timed barium swallow are useful imaging studies that may contribute to the diagnosis of achalasia and may be used to determine improvement after treatment. Esophagography is also ideally suited to evaluate potential post treatment complications. Treatment options for achalasia aim to disrupt the high-pressure LES to improve esophageal emptying, improve symptoms and prevent further dilatation of the esophagus. The most common treatment options currently include esophageal botulinum toxin (Botox) injections, pneumatic dilatation, Heller myotomy (often performed in conjunction with a fundoplication) and peroral endoscopic myotomy. Potential complications of these procedures may include intramural dissection, leak, scarring and fibrosis of the lower esophagus, strictures and problems related to gastroesophageal reflux and its associated complications. Radiologists must be aware of expected findings and potential complications following these procedures for timely and accurate diagnoses. The purpose of this paper is to describe treatment options for achalasia, illustrate expected imaging findings as well as imaging findings of potential early and long-term complications following treatment for achalasia.

Three-to-six month post-POEM timed barium esophagram can predict esophageal contents and may stratify aspiration risk on follow-up EGD

BACKGROUND

Peroral endoscopic myotomy (POEM) is an increasingly utilized endoscopic therapy for achalasia. When undergoing esophagogastroduodenoscopy (EGD), patients with a diagnosis of achalasia may receive endotracheal intubation (EI) to reduce the risk of aspiration. The risk of aspiration on post-POEM EGD should be reduced due to improved esophageal emptying. Despite history of myotomy, treated achalasia patients frequently receive EI on follow-up EGD increasing costs, procedural time, and potential risks from anesthesia. We determined if timed barium esophagram (TBE) findings three to six months after POEM predict the presence of esophageal contents on follow up endoscopy which may indicate aspiration risk.

METHODS

We identified achalasia patients who underwent POEM from September 2021 to October 2023 and had both a follow-up TBE and EGD three to six months later. At our institution, all achalasia patients are instructed to avoid solid oral intake (liquids allowed) for 2 days prior to pre-and post-POEM EGD. Predictors of esophageal contents were identified and receiver operating characteristic (ROC) curves were constructed to determine column heights that correspond to the presence of esophageal contents.

RESULTS

We identified 48 patients meeting inclusion criteria. Increasing barium column height at 5 min was associated with liquid/solid esophageal contents on EGD (OR: 1.36; p = 0.004). The receiver operating characteristics curve for esophageal contents demonstrated an area under the curve of 0.85 at 7 cm. Passage of a 13 mm tablet was inversely associated with the presence of esophageal contents (OR: 0.03; p = 0.002).

CONCLUSION

In post-POEM achalasia patients, follow-up TBE at 3-6 months demonstrating a 5-minute barium column height of less than 7.0 cm and passage of a 13 mm barium tablet may predict an esophagus free of liquid/solids during follow-up EGD after a 2-day solid fast. This study adds to our knowledge that TBE findings are a good predictor of esophageal emptying post-POEM, and may be used to predict which patients may be at risk of having residual esophageal contents and therefore need EI.

North American Expert Consensus on the Post-procedural Care of Patients After Per-oral Endoscopic Myotomy Using a Delphi Process

BACKGROUND & AIMS

There is significant variability in the immediate post-operative and long-term management of patients undergoing per-oral endoscopic myotomy (POEM), largely stemming from the lack of high-quality evidence. We aimed to establish a consensus on several important questions on the after care of post-POEM patients through a modified Delphi process.

METHODS

A steering committee developed an initial questionnaire consisting of 5 domains (33 statements): post-POEM admission/discharge, indication for immediate post-POEM esophagram, peri-procedural medications and diet resumption, clinic follow-up recommendations, and post-POEM reflux surveillance and management. A total of 34 experts participated in the 2 rounds of the Delphi process, with quantitative and qualitative data analyzed for each round to achieve consensus.

RESULTS

A total of 23 statements achieved a high degree of consensus. Overall, the expert panel agreed on the following: (1) same-day discharge after POEM can be considered in select patients; (2) a single dose of prophylactic antibiotics may be as effective as a short course; (3) a modified diet can be advanced as tolerated; and (4) all patients should be followed in clinic and undergo objective testing for surveillance and management of reflux. Consensus could not be achieved on the indication of post-POEM esophagram to evaluate for leak.

CONCLUSIONS

The results of this Delphi process established expert agreement on several important issues and provides practical guidance on key aspects in the care of patients following POEM.

Long-term efficacy of on-demand vonoprazan treatment for mild reflux esophagitis: success rates and predictors of treatment failure

BACKGROUND

Concerns surrounding long-term proton pump inhibitor use have prompted the exploration of alternative treatments for reflux esophagitis (RE). We previously demonstrated that 24 weeks of on-demand treatment with vonoprazan, a potassium-competitive acid blocker, effectively managed mild RE (Los Angeles classification grade A/B) in more than 80% of patients. However, its long-term efficacy remains unknown. Therefore, the present study investigated sustained effectiveness.

METHODS

We conducted a retrospective observational study on 30 participants with mild RE from our previous research. Participants with recurrent RE or symptom exacerbation were excluded and considered as treatment failure. Participants with the remission of RE and reflux symptoms under on-demand treatment until the clinic visit between October 2023 and February 2024 were regarded as treatment success. Predictors of treatment failure were analyzed.

RESULTS

During the observation period, 5 participants failed treatment due to symptom exacerbation and 6 due to recurrent RE. Five participants were excluded from analyses due to non-GERD causes. Fourteen participants (56.0%) successfully continued on-demand treatment for 91.5 months [89.3-92.8]. Age > 67 years significantly predicted treatment failure with a sensitivity of 72.7% and specificity of 85.7%. Although none of the patients with RE grade A had recurrent RE, it was not a significant difference.

CONCLUSIONS

Approximately 50% of patients with mild RE successfully continued on-demand treatment for more than 7 years. Age > 67 years was identified as a predictor of treatment failure. Prospective multi-center studies are warranted to validate these results.

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

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

Peroral endoscopic myotomy for achalasia and patients with normal lower-esophageal-sphincter integrated relaxation pressure: A propensity-score-matched retrospective study

BACKGROUND

Most patients who were included in previous studies on achalasia had increased lower esophageal sphincter (LES) pressure. Peroral endoscopic myotomy (POEM) has been confirmed to be effective at relieving the clinical symptoms of achalasia associated with increased LES pressure.

AIM

To identify the safety and efficacy of POEM for patients with normal LES integrated relaxation pressure (LES-IRP).

METHODS

The clinical data of patients who underwent POEM successfully in The First Medical Center of Chinese PLA General Hospital were retrospectively analyzed. A total of 481 patients who underwent preoperative high-resolution manometry (HRM) at our hospital were ultimately included in this research. According to the HRM results, the patients were divided into two groups: 71 patients were included in the normal LES-IRP group (LES-IRP < 15 mmHg) and 410 patients were included in the increased LES-IRP group (LES-IRP ≥ 15 mmHg). Clinical characteristics, procedure-related parameters, adverse events, and outcomes were compared between the two groups to evaluate the safety and efficacy of POEM for patients with normal LES-IRP.

RESULTS

Among the 481 patients included in our study, 209 were males and 272 were females, with a mean age of 44.2 years. All patients underwent POEM without severe adverse events. The median pre-treatment Eckardt scores of the normal LES-IRP and increased LES-IRP groups were 7.0 and 7.0 (P = 0.132), respectively, decreasing to 1.0 and 1.0 post-treatment (P = 0.572). The clinical success rate of the normal LES-IRP group was 87.3% (62/71), and that of the increased LES-IRP group was 91.2% (374/410) (P = 0.298). Reflux symptoms were measured by the GerdQ questionnaire, and the percentages of patients with GerdQ scores ≥ 9 in the normal LES-IRP and increased LES-IRP groups were 8.5% and 10.7%, respectively (P = 0.711). After matching, the rates of clinical success and the rates of GerdQ score ≥ 9 were not significantly different between the two groups.

CONCLUSION

Our results suggest that POEM is safe and effective for achalasia and patients with normal LES-IRP. In addition, in patients with normal LES-IRP, compared with those with increased LES-IRP, POEM was not associated with a greater incidence of reflux symptoms.

Differences in medical care satisfaction of patients with "functional" vs "organic" esophageal diseases, Italian validation of the PPRS SF questionnaire

Patient-physician relationship (PPR) plays a key role in modern healthcare, especially within gastrointestinal medical practice. In 2017 Kurlander et al. developed a Patient-Physician-Relationship-Scale (PPRS), a questionnaire used to assess the patients' medical care-satisfaction. The PPRS was later simplified by Drossman et al. in 2021 by creating a PPRS-SF (short form). This study aimed to validate the PPRS-SF in Italian and to administer it to patients with "functional" and "organic" esophageal diseases, to highlight the differences in the PPR between the two categories. The process of validation was carried out following a standardized forward-backward procedure and each step was overseen by a Rome foundation independent clinical monitor. The Italian version of the PPRS-SF was then administered to 50 Eosinophilic Esophagitis (EoE), 53 Achalasia, 48 Gastroesophageal Reflux Disease (GERD) and 44 esophageal disorders of gut brain interaction (eDGBI) patients. In eDGBI and GERD, the degree of patients' satisfaction was significantly lower. Between a score of -36 and + 36, the mean score for patients with EoE was 30.20 (± 9.78), for Achalasia 23.78 (± 19.9); for GERD 20.46 (± 16.03) and for esophageal DGBI 17.91 (± 18.41). Moreover, there was a negative significant correlation between the PPR and age (R=- 0.208). This study validated the Italian version of the PPRS-SF questionnaire and showed that the patients' diagnosis together with other factors such as their age, can affect the PPR. In particular, patients with DGBI and older patients reported lower scores than the ones with organic diseases and the younger ones, respectively.

Peroral endoscopic myotomy with fundoplication (POEM-F) for achalasia: Systematic review and meta-analysis

Background and study aims

Gastroesophageal reflux (GER) and its long-term sequelae remain a concern following peroral endoscopic myotomy (POEM). POEM with fundoplication (POEM-F) is simultaneous fundoplication via pure natural orifice transluminal endoscopic surgery (NOTES). In this study, we evaluated the efficacy and safety of POEM-F in mitigating post-POEM GER.

Methods

We performed a comprehensive electronic database search from January 2008 through June 2024 for studies evaluating outcomes of POEM-F performed for managing post-POEM GER. Pooled proportions were calculated using random-effects models. Heterogeneity was assessed using I 2 and Q statistics.

Results

We included seven studies comprising 127 patients. Pooled technical success for POEM was 96.90%; 95% confidence interval [CI] 91.40-98.90. Pooled technical success of fundoplication was 92.30%; 95% CI 85.20-96.10. Clinical success in treating achalasia was 96.40%; 95% CI 90.70-98.60. Rate of wrap integrity on follow-up was 84.00%; 95% CI 66.00-93.40. Composite clinical success of POEM-F in mitigating post-POEM GER was 86.20%; 95% CI 73.80-93.20. Mean total procedure duration and fundoplication time was 115.74 minutes; 95% CI 103.53-126.96 and 55.28 minutes; 95% CI 47.35-63.20, respectively. The overall pooled major adverse events (AE) rate was 3.60%; 95% CI 1.40-9.40.

Conclusions

POEM-F is an effective procedure with an acceptable AE rate in expert hands. It appears to offer clinical benefit in mitigating post-POEM GER. However, further standardization for evaluating clinically significant post-POEM GER and long-term benefit of POEM-F is warranted.

Long-term outcomes of pneumatic balloon dilation versus peroral endoscopic myotomy in type I and II achalasia patients: a propensity score-matched analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) shows higher efficacy than pneumatic balloon dilation (PBD) for type I and II achalasia over 2 years. However, long-term durability beyond 5 years remains under-investigated. This study assessed the long-term efficacy of PBD versus POEM.

METHODS

This retrospective comparative study examined treatment-naïve achalasia patients who underwent either PBD or POEM. Cohort balance was achieved through propensity score (PS) matching based on age, sex, Eckardt score, and Charlson Comorbidity Index. The primary outcome was the time to a second intervention. Secondary outcomes were treatment failure, Eckardt score, number of intervention sessions, weight gain, and adverse events.

RESULTS

Of the 127 patients, 67 underwent PBD and 60 underwent POEM, with an average follow-up of 7 years (interquartile range, 5-10). After PS matching, 100 patients with 1:1 matching were included in the analysis. Baseline characteristics, including clinical, endoscopic, and manometric attributes, were comparable between groups. The POEM group had a significantly longer time to a second intervention than the PBD group (hazard ratio, .139; 95% confidence interval, .048-.405) and underwent less endoscopic sessions (P < .001 by linear marginal model analysis) within the first 2 years. Beyond 2 years, subsequent interventions were comparable between groups. There were no differences in the Eckardt score or weight gain. Hospital stays were shorter in the PBD group (2 vs 4 days, P < .001). POEM patients had more adverse events, including perforation.

CONCLUSIONS

POEM demonstrated greater long-term durability than PBD, but PBD was associated with shorter hospital stays and fewer adverse events.

Phase concept: Novel dynamic endoscopic assessment of intramural antireflux mechanisms (with video)

OBJECTIVES

The gastroesophageal junction (GEJ) consists of various anatomical components that together form a barrier to prevent reflux of gastric content. This study introduces a novel phase concept to dynamically evaluate the antireflux barrier (ARB) during endoscopy and analyzes its functionality.

METHODS

We reviewed previously the recorded endoscopic videos of subjects who underwent the endoscopic pressure study integrated system (EPSIS) from February to April 2024 for indications other than gastroesophageal reflux disease symptoms. This device was used as an auxiliary tool to measure intragastric pressure (IGP) during endoscopy with a retroflex view. The ARB dynamic was divided into three phases: Phase I (gastric phase), Phase II (lower esophageal sphincter phase), and Phase III (esophageal clearance phase). We evaluated the morphological changes in the ARB during insufflation using EPSIS.

RESULTS

The median age of the 30 subjects was 58 years (interquartile range [IQR] 46.5-68.8), including 20 men and 10 women. Endoscopic findings and IGPs were recorded during the three phases. In Phase I, at low IGP (median 6.75 mmHg), the gastroesophageal flap valve and longitudinal folds were observed in 80% of cases. In Phase II, at moderate IGP (median 11.8 mmHg), the scope holding sign was observed in 86.7%. In Phase III, at high IGP (median 19 mmHg) inducing belching, peristalsis was observed in 80% of cases with median recovery time of 5 s.

CONCLUSION

The phase concept provides a valuable framework for understanding the antireflux mechanism. Further research is needed to validate these findings in GEJ disorders and explore correlations with other modalities.

Achalasia: Diagnosis and Management

Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Typical symptoms of achalasia are dysphagia, retrosternal chest pain, regurgitation, and weight loss. Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.

The Contemporary Diagnostic Approaches to Esophageal Symptomatology

Esophageal symptoms, including dysphagia, heartburn, and non-cardiac chest pain, are prevalent concerns in gastroenterology. This review examines the roles of advanced diagnostic modalities such as high-resolution manometry (HRM), pH-impedance monitoring, and EndoFLIP in understanding esophageal physiology and pathology. Here, we discuss the clinical presentations of common esophageal symptoms and explore how structural abnormalities like strictures and motility disorders, including achalasia and esophageal spasms, are assessed using these tools. The diagnostic utility of endoscopy in visualizing mucosal and structural changes is highlighted alongside emerging technologies like artificial intelligence in enhancing detection capabilities. Complementary techniques, such as barium esophagrams and reflux monitoring, provide additional functional and anatomical insights, crucial for comprehensive patient evaluation. The integration of these diagnostic approaches fosters a deeper understanding of esophageal disorders, guiding effective management strategies and improving patient outcomes. This review aimed to highlight the importance of adopting a multimodal diagnostic approach in modern gastroenterological practice.

The A to Z of Peroral Endoscopic Myotomy

Peroral endoscopic myotomy (POEM) is a novel technique within the field of third space endoscopy. The overarching principal is creation of a mucosal incision, careful dissection of the submucosal space using an electrosurgical knife to reach the muscularis (ie, tunneling), performing a controlled myotomy, and finally, closure of the mucosal incision. POEM was first developed for the management of achalasia, and now a decade of evidence shows the procedure is safe, effective, and highly reproducible. Since then, the indications for POEM have expanded to a range of benign upper gastrointestinal (GI) pathologies including cricopharyngeal bar (C-POEM), Zenker's diverticulum (Z-POEM), esophageal diverticula (D-POEM), and gastroparesis (G-POEM). POEM offers the benefit of a minimally invasive alternative to surgical intervention with high clinical success and low rate of adverse events. As the field expands, there is need for more high-quality prospective evidence for the use of POEM within the upper GI tract akin to the ground-breaking work that has been achieved in achalasia. Within this review, we discuss the 5 main indications for POEM, the technical aspects of each corresponding procedure, and analyze the current evidence supporting their use in clinical practice.

Esophageal Motility Disorders: A Concise Review on Classification, Diagnosis, and Management

Esophageal motility disorders (EMDs) are an underrecognized cause of dysphagia and encompass a breadth of conditions, including achalasia, esophagogastric junction outflow obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility. Whereas patients with EMDs classically present with dysphagia to both solids and liquids, other symptoms such as heartburn, noncardiac chest pain, and regurgitation may also be present. The advent and standardization of high-resolution esophageal manometry by the Chicago Classification have revolutionized the diagnosis and management of EMDs. The EMDs are broadly classified into disorders of the esophagogastric junction (achalasia, esophagogastric junction outflow obstruction) and peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus, ineffective esophageal motility). Additional tests, such as timed barium esophagogram and EndoFLIP, can help provide adjunctive information in cases in which high-resolution esophageal manometry findings are inconclusive. Management varies widely according to the type of EMD and can range from lifestyle and dietary modifications to oral pharmacologic therapy and various endoscopic or surgical interventions. In patients with achalasia, durable management aimed at the lower esophageal sphincter should strongly be considered. This clinical review aims to provide a concise yet comprehensive summary on classification, diagnosis, and management of EMDs.

Efficacy of laparoscopic cardiectomy combined with side overlap anastomosis for the treatment of terminal achalasia

To investigate the safety and short-term effectiveness of laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction for the treatment of terminal or end-stage achalasia, patients with end-stage achalasia treated with laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction were retrospectively enrolled. The clinical data, surgical data and follow-up were analyzed. Among twenty-five patients enrolled, the achalasia type St was present in 12 (48%) patients, type Sg in 9 (36%), and type aSg in 4 (16%). The surgical time ranged 60-180 min (median 100 min) with an intraoperative blood loss 20-200 ml (median 50 ml). Five (20%) patients experienced complications within a week after surgery, with fever (> 38.5 ℃) in two (40%) patients within 3 days after surgery, abdominal incision infection in one (20%), and anastomotic leak in two (40%). The postoperative hospitalization time ranged 8-44 (median 10) days. Follow-up was conducted 6-38 months (median 16) after surgery. Compared with the preoperative Eckardt score (7.64 ± 1.32), the Eckardt score was significantly (P < 0.01) decreased at one month (0.52 ± 0.87), 6 (0.84 ± 1.11) and 12 (1.23 ± 1.23) months after surgery in all patients. The Eckardt score in type St was significantly (P < 0.05) smaller than in type Sg or aSg at 6 and 12 months after surgery. Seven patients maintained an Eckardt score 0 with complete relief of their symptoms. The effective rate was 100% for type St, 88.8% for type Sg, and 75% for type aSg. The effective rates at 1 month, 6 and 12 months after surgery were 100% (95% CI: 100% -100%), 96% (95% CI: 87.7 -100%), and 92% (95% CI: 80.6 -100%). Two patients were diagnosed with gastroesophageal reflux disease (GERD) at the end of the follow-up. The cumulative incidence of GERD at 1 month, 6 and 12 months after surgery was 0, 4% (95% confidence interval or CI: 0-12.3%), and 8% (95% CI: 0-19.4%). In conclusion, the laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction is safe and effective for the treatment of end-stage achalasia, and the effect is significantly better for achalasia type St than for types Sg and aSg.

A unique achalasia patient complicated by neuropathies associated with nutritional deficiencies

This paper reported a rare case of achalasia patient postoperatively experiencing a series of neurologic symptoms, diagnosed as severe B vitamin deficiencies caused by central and peripheral damage.

Neurogastroenterology and motility disorders in patients with cirrhosis

Neurogastroenterology and motility disorders are complex gastrointestinal conditions that are prevalent worldwide, particularly affecting women and younger individuals. These conditions significantly impact the quality of life of people suffering from them. There is increasing evidence linking these disorders to cirrhosis, with a higher prevalence compared to the general population. However, the link between neurogastroenterology and motility disorders and cirrhosis remains unclear due to undefined mechanisms. In addition, managing these conditions in cirrhosis is often limited by the adverse effects of drugs commonly used for these disorders, presenting a significant clinical challenge in the routine management of patients with cirrhosis. This review delves into this connection, exploring potential pathophysiological links and clinical interventions between neurogastroenterology disorders and cirrhosis.

Achalasia: beyond the basics

Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.

Exploring the relaxation effects of Coptis chinensis and berberine on the lower esophageal sphincter: potential strategies for LES motility disorders

BACKGROUND

Esophageal achalasia, a primary disorder impacting the lower esophageal sphincter (LES), presents symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Traditional treatments, including calcium channel blockers and nitrates, offer limited relief, prompting exploration into alternative therapies. This study examines the efficacy of Traditional Chinese Medicine (TCM), focusing on Coptis chinensis (C. chinensis) and its principal component, berberine, for modulating LES relaxation, offering a new perspective on treatment possibilities.

METHODS

This research evaluated the impact of C. chinensis extract and berberine on the relaxation of LES contraction pre-induced by carbachol, observing the effects across different concentrations. We employed a series of inhibitors, including tetrodotoxin, ω-conotoxin GVIA, rolipram, vardenafil, KT5823, KT5720, NG-nitro-L-arginine, tetraethylammonium (TEA), apamine, iberiotoxin, and glibenclamide, to investigate the underlying mechanisms of berberine-induced LES relaxation.

RESULTS

Both C. chinensis extract and berberine induced significant, concentration-dependent relaxation of the LES. The relaxation effect of berberine was significantly reduced by TEA, indicating the involvement of potassium channels in this process.

CONCLUSIONS

This study demonstrates that C. chinensis and berberine significantly promote LES relaxation, primarily through potassium channel activation. These findings provide a foundation for further investigation of these compounds' potential therapeutic applications in esophageal motility disorders, such as achalasia.

Own Experience in the Use of Artificial Intelligence Technologies in the Diagnosis of Esophageal Achalasia

Aim: to demonstrate an artificial intelligence model that optimises the differential diagnosis of achalasia.

Material and methods. The study included 75 patients: 52 % men (mean age 44.5 ± 17.8 years) and 48 % women (mean age 45.6 ± 16.6 years,) with a preliminary diagnosis of achalasia. Patients were divided into four groups: type I, II, III achalasia and a group of patients whose results did not correspond to a diagnosis of achalasia according to HRM performed based on Chicago Classification version 4.0. On the basis of a set of data from 750 swallows and therefore 6750 manometric parameters, the artificial intelligence models DecisionTreeClassifier, RandomForestClassifier and CatBoostClassifier have been trained to provide a manometric diagnosis. The comparison criteria were the training time and the f1_score metric. The technical characteristics of the model (hyperparameters) were selected using the GridSearchCV method. The model with the best results was integrated into a web application.

Results. The RandomForestClassifier was chosen as the best performing model to compare. Its technical characteristics were “decision trees” and branching depth the number of which was 14 and 5 respectively. With a maximum possible value of 1.0, these hyperparameters achieved f1_score=0.91 in 27 seconds. The web application, developed on the basis of this model, is capable of analyzing manometric data and establishing one of three types of achalasia in patients. Alternatively, it can exclude the diagnosis of achalasia. The output of an image corresponding to the diagnosis is produced for each manometric type of the disease.

Conclusions. For the first time in Russia, a machine learning model based on high-resolution esophageal manometry data was developed at the V. Kh. Vasilenko Clinic of Internal Disease Propedeutics, Gastroenterology, and Hepatology of Sechenov University. The model has been applied to the creation of a web application which has the ability to substantiate the manometry diagnosis of patients. The Federal Service for Intellectual Property (Rospatent) issued a certificate of state registration of the computer program No. 2024665795 dated July 5, 2024. This artificial intelligence programme can be used in clinical practice as a medical decision support tool to optimize the process of differential diagnosis of achalasia and early detection of the disease, to determine the patient's prognosis and to select the method of further treatment.

Association of circulating cytokine levels and tissue-infiltrating myeloid cells with achalasia: results from Mendelian randomization and validation through clinical characteristics and single-cell RNA sequencing

BACKGROUND

Achalasia is a rare motility disorder of the esophagus often accompanied by immune dysregulation, yet specific underlying mechanisms remain poorly understood.

METHODS

We utilized Mendelian randomization (MR) to explore the causal effects of cytokine levels on achalasia, with cis-expression/protein quantitative trait loci (cis-eQTLs/pQTLs) for 47 cytokines selected from a genome-wide association study (GWAS) meta-analysis and GWAS data for achalasia obtained from FinnGen. For cytokines significantly linked to achalasia, we analyzed their plasma concentrations and expression differences in the lower esophageal sphincter (LES) using enzyme-linked immunosorbent assay and single-cell RNA sequencing (scRNA-seq) profiling, respectively. We further employed bioinformatics approaches to investigate underlying mechanisms.

RESULTS

We revealed positive associations of circulating Eotaxin, macrophage inflammatory protein-1b (MIP1b), soluble E-selectin (SeSelectin) and TNF-related apoptosis-inducing ligand (TRAIL) with achalasia. When combining MR findings with scRNA-seq data, we observed upregulation of TRAIL (OR = 2.70, 95% CI, 1.20-6.07), encoded by TNFSF10, in monocytes and downregulation of interleukin-1 receptor antagonist (IL-1ra) (OR = 0.70, 95% CI 0.59-0.84), encoded by IL1RN, in FOS_macrophages in achalasia. TNFSF10high monocytes in achalasia displayed activated type I interferon signaling, and IL1RNlow FOS_macrophages exhibited increased intercellular communications with various lymphocytes, together shaping the proinflammatory microenvironment of achalasia.

CONCLUSIONS

We identified circulating Eotaxin, MIP1b, SeSelectin and TRAIL as potential drug targets for achalasia. TNFSF10high monocytes and IL1RNlow macrophages may play a role in the pathogenesis of achalasia.

Upper Esophageal Sphincter Abnormalities and Esophageal Motility Recovery After Peroral Endoscopic Myotomy for Achalasia

Abnormalities in the upper esophageal sphincter (UES) in patients with achalasia and the impact of peroral endoscopic myotomy (POEM) on the UES and esophageal body remain uncertain. To outline the prevalence and nature of UES abnormalities across different achalasia subtypes, as well as evaluate POEM's therapeutic efficacy on UES and esophageal body. A retrospective study of patients diagnosed with achalasia between January 2019 and December 2023 was conducted. POEM was performed on all patients, and preoperative and 6-month postoperative high-resolution esophageal manometry (HREM) data were obtained, along with the Eckardt symptom scores. A total of 64 patients (34 females, 30 males) who underwent POEM for achalasia (type I: 18, type II: 38, type III: 8) during the study period were included. Among the 64 patients, 42 (65.6%) exhibited abnormalities in the UES, as observed on HREM. The majority of those exhibiting abnormalities demonstrated impaired relaxation of the UES (46.9%), followed by a combination of hypertensive basal UES pressure (UESP) and impaired UES relaxation (12.5%). The dysphagia score and Eckardt score before POEM were significantly greater in the UES abnormality group than in the normal UES group (2.3 ± 0.7 vs. 1.9 ± 0.7, p = 0.040 and 6.2 ± 1.8 vs. 5.0 ± 1.6, p = 0.008, respectively). UESP and UES relaxation pressure (UESRP) decreased significantly following POEM across all types of achalasia (p < 0.05). All type I patients continued to exhibit no contractility after undergoing POEM. Pan-esophageal pressurization and spastic contractions were absent in patients with type II and type III achalasia following POEM. The high prevalence of UES abnormalities among patients with achalasia may serve as a compensatory mechanism. Patients with type II and III showed partial recovery of peristalsis following POEM.

Surgical management of achalasia

Achalasia is a chronic esophageal motility disorder comprised of ineffective esophageal peristalsis and incomplete relaxation of the lower esophageal sphincter. This disease had historically been managed through medical means as well as endoscopic dilations. However, surgical interventions are now considered standard of care, including minimally invasive Heller myotomy, which was popularized in 1990s, followed by per oral endoscopic myotomy in the 2010s. Both surgical approaches provide acceptable resolution of dysphagia symptoms. Classification of the achalasia as well as other patient-level factors may drive the clinical decision-making between the two approaches, as well as surgical training and surgeon preference.

Repeat peroral endoscopic myotomy: technical difficulty and risk factors

BACKGROUND AND AIMS

Repeat peroral endoscopic myotomy (Re-POEM) appears to be a promising salvage option for patients with persistent or recurrent symptoms after initial POEM, but it may be more technical challenging. Here we aim to evaluate the safety and technical difficulty of Re-POEM.

METHODS

Between July 2012 and October 2023, 158 achalasia patients underwent Re-POEM and were retrospectively enrolled. Another 2978 patients without prior myotomy were selected for the naive POEM group. After propensity score matching (PSM), procedure-related parameters were compared between the 2 groups. Univariable and multivariable analyses were performed to reveal risk factors for difficult Re-POEM (defined as procedure time ≥90 minutes).

RESULTS

With similar baseline characteristics between the 2 groups after PSM, the procedure time was comparable between Re-POEM and naive POEM groups (61.4 ± 27.0 vs 59.3 ± 29.9, P = .496). The Re-POEM group had a shorter esophageal myotomy length (7.0 ± 2.1 cm vs 8.2 ± 1.1 cm, P < .001) and longer gastric myotomy length (2.3 ± .6 cm vs 2.1 ± .4 cm, P = .017) compared with the naive POEM group. Mucosal injury in the Re-POEM group was slightly higher, which was not statistically significant (20.3% vs 13.9%, P = .135). No differences were found in the incidence of gas-related adverse events (AEs), major AEs, and technical difficulty. Multivariate analysis determined mucosal edema (odds ratio, 4.942; 95% confidence interval, 1.554-15.714; P = .007) and submucosal fibrosis (odds ratio, 3.817; 95% confidence interval, 1.333-10.931; P = .013) to be independent risk factors for difficult Re-POEM.

CONCLUSIONS

Re-POEM appears to be safe and feasible as a salvage option after initial POEM failure, with comparable procedure duration, incidence of AEs, and technical difficulty with naive POEM. Mucosal edema and submucosal fibrosis were associated with difficult Re-POEM.

Achalasia: diagnostic delay and manometric characteristics with high-resolution solid-state and perfusion equipment

INTRODUCTION

the early diagnosis of achalasia requires a high degree of clinical suspicion, and delays in diagnosis are frequent. High-resolution esophageal manometry (HRM) is the gold standard for its diagnostic confirmation. There are two HRM systems, perfusion and solid-state, which allow its classification into three subtypes: I, or classical; II, or with pan-esophageal pressurization; and III, or spastic.

OBJECTIVE

to determine the clinical and manometric characteristics of the three subtypes with high-resolution perfusion and solid-state equipment and the time of evolution until diagnosis.

METHODS

this was a multicenter, observational, retrospective study of patients from the INTEGRA database of the Spanish Association of Neurogastroenterology and Motility who were diagnosed with primary achalasia confirmed by HRM, who fell under the Chicago Classification v3.0, and who had not been treated.

RESULTS

the study included 110 patients (subtype I, n = 14; subtype II, n = 73; subtype III, n = 23). The HRM equipment was perfusion for 49 and solid-state for 61. The mean age was 61.8 ± 14 years (age range 44-81), the age was lower in subtype II, and sex distribution was similar. The time of clinical evolution until diagnosis was > 12 months (51.6 %), subtype II being the one that was diagnosed earlier and the most often (66.3 %). Dysphagia was the most frequent symptom (90.5 %). According to the comparative analysis by high-resolution perfusion and solid-state esophageal manometry equipment, the baseline pressure of the lower esophageal sphincter was higher in the solid-state esophagus, but the difference was not statistically significant. The median integrated relaxation pressure at four seconds (IRP4) was similar (21 mmHg) between the perfusion and solid-state measurements. We describe the ranges of IRP4 in achalasia patients with both systems and confirm the possibility of achalasia even when IRP4 is within the normal range.

CONCLUSIONS

achalasia in our environment has a significant diagnostic delay. No significant differences were observed in the esophagogastric junction between the two groups diagnosed with perfusion and solid-state equipment.

Patients with cardinal symptoms of eosinophilic esophagitis. Prejudice affects clinical practice…

INTRODUCTION

Dysphagia and bolus impaction are the cardinal manifestations of eosinophilic esophagitis (EoE). Esophageal biopsy sampling is mandatory for EoE diagnosis, data though suggest that clinician do not always obtain biopsies from patients with cardinal EoE symptoms during upper gastrointestinal endoscopy even if no other entity than EoE can explain patients symptoms. We aimed to search for the esophageal biopsy procurement rate as also for factors that drive clinicians to obtain esophageal biopsies among patients with cardinal EoE symptoms.

METHODS

We retrospectively searched for patients with cardinal EoE symptoms submitted to upper gastrointestinal endoscopy between 1/2018 and 12/2023 in our department. Epidemiologic, clinical, endoscopic, and histological data were analyzed.

RESULTS

In total 163 patients with cardinal EoE symptoms (dysphagia: 63 and bolus impaction: 100) were included in the study (M/F: 100/63, mean age: 54 ± 22 years). Biopsy sampling was obtained in 77/163 (47.2%) patients and sampling rates did not differ between patients with bolus impaction or dysphagia (47/100, 47% vs 30/63, 47.6%, P  = 0.553). Higher rates of sampling were observed in males ( P  = 0.045), those younger than 65 years old ( P  < 0.001) and patients with endoscopic EoE signs ( P  = 0.004). Age and endoscopic findings compatible to EoE were independently correlated to biopsy sampling. EoE was diagnosed in 35/74 patients (47.3%); the majority of patients were male, with a bolus impaction episode, compatible endoscopic findings and all were younger than 65 years old.

CONCLUSION

Clinicians take esophageal biopsies in half of patients with cardinal EoE. Age and supportive endoscopic evidence drive clinicians' decision to obtain esophageal biopsies.

Identification of Achalasia Within Absent Contractility Phenotypes on High-Resolution Manometry: Prevalence, Predictive Factors, and Treatment Outcome

INTRODUCTION

Absent contractility on high-resolution manometry (HRM) defines severe hypomotility but needs distinction from achalasia. We retrospectively identified achalasia within absent contractility using HRM provocative maneuvers, barium esophagography, and functional lumen imaging probe (FLIP).

METHODS

Adult patients with absent contractility on HRM during the 4-year study period were eligible for inclusion. Inadequate studies, achalasia after therapy, or prior foregut surgery were exclusions. Upright integrated relaxation pressure (IRP) >12 mm Hg, panesophageal pressurization, and/or elevated IRP on multiple rapid swallows and rapid drink challenge (RDC) were considered abnormal. Esophageal barium retention and abnormal esophagogastric junction distensibility index (<2.0 mm 2 /mm Hg) on FLIP defined achalasia. Clinical, endoscopic, and motor characteristics of patients with achalasia were compared with absent contractility without obstruction.

RESULTS

Of 164 patients, 20 (12.2%) had achalasia (17.9% of 112 patients with adjunctive testing), while 92 did not, and 52 did not undergo adjunctive tests. Achalasia was diagnosed regardless of IRP value, but the median supine IRP was higher (odds ratio 1.196, 95% confidence interval 1.041-1.375, P = 0.012). Patients with achalasia were more likely to present with dysphagia (80.0% vs 35.9%, P < 0.001), with obstructive features on HRM maneuvers (83.3% vs 48.9%, P = 0.039), but lower likelihood of GERD evidence (20.0% vs 47.3%, P = 0.027) or large hiatus hernia (15.0% vs 43.8%, P = 0.002). On multivariable analysis, dysphagia presentation ( P = 0.006) and pressurization on RDC ( P = 0.027) predicted achalasia, while reflux and presurgical evaluations and lack of RDC obstruction predicted absent contractility without obstruction.

DISCUSSION

Despite HRM diagnosis of absent contractility, achalasia is identified in more than 1 in 10 patients regardless of IRP value.

Comparison of laparoscopic Heller myotomy and endoscopic balloon dilation in the treatment of achalasia: Effects on quality of life and patient satisfaction

BACKGROUND

Achalasia is a rare neurodegenerative disease of the esophagus that causes impaired esophageal peristalsis and the inability of the lower esophageal sphincter (LES) to relax. This results in symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Among the treatment options, Laparoscopic Heller Myotomy (LHM), Endoscopic Balloon Dilation (EBD), and Peroral Endoscopic Myotomy (POEM) are commonly used methods. The aim of this study was to compare the efficacy and clinical long-term results of LHM and EBD in treating achalasia.

METHODS

Patient records from Bezmialem Vakıf University Hospital were reviewed, and 36 patients diagnosed with achalasia who underwent LHM and EBD were included in the study. Patients were evaluated using the Pre-operative Eckardt Score (Pre-ES) for preoperative evaluation, the Post-operative Eckardt Score (Post-ES) for postoperative evaluation, the Achalasia Specific Quality of Life (ASQL) questionnaire, and the Patient Satisfaction Scoring (PSS).

RESULTS

The mean age of the 19 patients who underwent LHM was 49.37±10.48 years. The mean age of the 17 patients who underwent EBD was 59.24±14.39 years. Perioperative complications included esophageal mucosal perforation in one patient in the LHM group, bleeding in three patients (17.64%), and esophageal perforation in one patient (5.88%) in the EBD group. At a mean follow-up of 90 months, gastroesophageal reflux developed in two patients (10.53%) in the LHM group and eight patients (47%) in the EBD group. The Pre-ES was similar in both groups. The Post-ES significantly decreased in the LHM group compared to the EBD group. When ASQL and PSS results were analyzed between the LHM and EBD groups, it was concluded that LHM was more effective than EBD in improving the quality of life and providing patient satisfaction (p-value: 0.001).

CONCLUSION

In light of these findings, it was concluded that LHM is a safer intervention compared to EBD and should be prioritized, considering the low risk of complications, improved quality of life, and high level of satisfaction.

Esophageal achalasia compressing the left atrium and mimicking an extracardiac tumor on the transthoracic echocardiography: A case report

Achalasia is an uncommon disorder affecting esophageal motility. Occasionally, the appearance of a dilated esophagus in achalasia may resemble an extracardiac tumor when observed through transthoracic echocardiography. Left atrial compression due to extensive esophageal dilation is also rare, potentially leading to hemodynamic compromise. Here, we present a rare case involving left atrial compression caused by esophageal dilation in achalasia, with echocardiographic findings mimicking those of an extracardiac tumor.

Safety and efficacy of peroral endoscopic myotomy for treating achalasia in pediatric and geriatric patients: A meta-analysis

BACKGROUND

As a less invasive technique, peroral endoscopic myotomy (POEM) has recently been widely accepted for treating achalasia with an excellent safety profile, durability, and efficacy in adults. In pediatric and geriatric patients, the treatment is more difficult.

AIM

To discuss the clinical outcomes of POEM in pediatric and geriatric patients with achalasia.

METHODS

We conducted a comprehensive search of PubMed, Embase and Cochrane Library databases from inception to July 2024. The primary outcomes were technical and clinical success. Secondary outcomes of interest included adverse events and gastroesophageal reflux disease (GERD). The pooled event rates were calculated by comprehensive meta-analysis software.

RESULTS

A total of 32 studies with 547 pediatric patients and 810 geriatric patients were included in this study. The pooled event rates of technical success, clinical success, GERD and adverse events of POEM for treating achalasia in pediatric patients were 97.1% [95% confidence interval (CI): 95.0%-98.3%; I² = 0%; P < 0.000], 93.2% (95%CI: 90.5%-95.2%; I² = 0%; P < 0.000), 22.3% (95%CI: 18.4%-26.7%; I² = 43.874%; P < 0.000) and 20.4% (95%CI: 16.6%-24.8%; I² = 67.217%; P < 0.000), respectively. Furthermore, in geriatric patients, the pooled event rates were 97.7% (95%CI: 95.8%-98.7%; I² = 15.200%; P < 0.000), 93.2% (95%CI: 90.3%-95.2%; I² = 0%; P < 0.000), 23.9% (95%CI: 19.4%-29.1%; I² = 75.697%; P < 0.000) and 10.8% (95%CI: 8.3%-14.0%; I² = 62.938%; P < 0.000], respectively.

CONCLUSION

Our findings demonstrated that POEM was an effective and safe technique for pediatric and geriatric patients with achalasia.

Clinical impact of esophageal muscle thickness on peroral endoscopic myotomy patients

BACKGROUND

Peroral endoscopic myotomy (POEM) is a standard procedure for achalasia, an esophageal motility disorder, characterized by a thickened lower esophageal sphincter muscularis propria (LEMP). Visualization of this anatomical stratification has been made possible by the advent of endoscopic ultrasound (EUS). However, the effect of LEMP thickness on treatment outcomes remains unclear. The objective of this study was to investigate whether LEMP thickness affects treatment response post-POEM.

METHODS

This was a single-center, prospective cohort study of patients who underwent POEM between 2014 and 2021. Patients who underwent EUS to evaluate the LEMP before POEM were included in the study. We divided the patients into two groups according to muscle thickness measured by EUS (≥ 2.80 mm; group 1, < 2.80 mm; group 2). The pre- and post-procedural clinical parameters were compared between the two groups.

RESULTS

Among 278 patients, 189 were enrolled. There were no significant differences in the pre- and post-Eckardt scores, integrated relaxation pressure, and distensibility index between the two groups divided by muscle thickness. Furthermore, there was no statistically significant difference in symptom recurrence, as measured by an Eckardt score > 3, post-procedural complications, or post-POEM GERD symptoms. However, patients with thicker lower esophageal sphincter muscle showed a greater decrease in Eckardt scores (ΔES ≥ 3) which was statistically significant (P = 0.002).

CONCLUSION

POEM is an effective and safe treatment method for achalasia, regardless of LES muscle thickness. There was a statistically significant difference in the decrease of Eckardt scores of 3 or greater (ΔES ≥ 3) after POEM in the thicker LEMP group suggesting greater alleviation of symptoms in POEM patients with thicker lower esophageal muscle.

Esophageal Per-Oral Endoscopic Myotomy (E-POEM): Future Directions and Perspectives

PURPOSE OF REVIEW

POEM is a mature procedure endorsed by societal guidelines as a first line therapy for achalasia and spastic esophageal disorders. Nonetheless, several questions remain, including expanding indications for POEM, periprocedural evaluation and management, and the optimal POEM technique to enhance clinical success while mitigating risk for reflux.

RECENT FINDINGS

There is uncertainty regarding several technical aspects of the POEM myotomy; though aggregating evidence supports the use of real-time impedance planimetry to guide the myotomy. While post-POEM reflux remains a concerning long term sequela, there is an increasing focus on the potential role of endoscopic anti-reflux interventions. Lastly, with the widespread adoption of POEM, we continue to witness ongoing efforts to standardize post-procedural care and training in this procedure. POEM is no longer a novel but rather established procedure. Yet, this technique has continued to evolve, with the aim of optimizing treatment success while reducing adverse events and risk for post-procedural reflux.

Relationship Between Lower Esophageal Sphincter Muscles Thickness and Their Response to Pneumatic Dilation in Patients With Achalasia

Background

Prognostic factors play a major role in managing achalasia patients treated with pneumatic dilatation (PD) and understanding the pathophysiology of the disease. In this regard, the muscular thickness of the lower esophageal sphincter (LES) has drawn attention in recently published studies.

Methods

Patients with newly diagnosed achalasia were included consecutively in this study, and Endoscopic Ultrasound (EUS) was used to determine the thickness of longitudinal and circular muscles of LES. To determine the recurrence of symptoms, patients were followed up for one year using the Eckardt questionnaire. The relationship between pre-treatment LES muscle thickness and symptom recurrence was investigated.

Results

Seventeen of nineteen treated patients were enrolled in this study and the data of sixteen patients was analyzed. Although not statistically significant, those with thinner LES had recurrent symptoms ( p-value = 0.08). Patients with a thicker LES (5.1 mm vs. 4.6 mm) initially responded better to pneumatic dilatation ( p-value = 0.03). After initial therapy, severe pain (daily pain) was strongly associated with symptom recurrence.

Conclusions

Severe retrosternal chest pain and a thin LES appear to be surrogate markers for advanced disease and poor outcomes. Pre-treatment integrated relaxation pressure (IRP) seems to be a promising predictor of PD prognosis. Due to the study's heterogeneous population, the findings cannot be generalized to all achalasia patients, and larger-scale studies are necessary to confirm these findings.

Nutritional Management of Pediatric Gastrointestinal Motility Disorders

Normal and optimal functioning of the gastrointestinal tract is paramount to ensure optimal nutrition through digestion, absorption and motility function. Disruptions in these functions can lead to adverse physiological symptoms, reduced quality of life and increased nutritional risk. When disruption or dysfunction of neuromuscular function occurs, motility disorders can be classified depending on whether coordination or strength/velocity of peristalsis are predominantly impacted. However, due to their nonspecific presenting symptoms and overlap with sensory disruption, they are frequently misdiagnosed as disorders of the gut-brain interaction. Motility disorders are a prevalent issue in the pediatric population, with management varying from medical therapy to psychological therapy, dietary manipulation, surgical intervention or a multimodal approach. This narrative review aims to discuss the dietary management of common pediatric motility disorders including gastroesophageal reflux, esophageal atresia, achalasia, gastroparesis, constipation, and the less common but most severe motility disorder, pediatric intestinal pseudo-obstruction.

Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand

BACKGROUND/AIMS

Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM.

METHODS

This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up.

RESULTS

Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017).

CONCLUSIONS

These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.

Review article: Oesophageal disorders in chronic liver disease

BACKGROUND

Oesophageal disorders and chronic liver disease are common worldwide and significantly impact quality of life. The intricate link between these conditions, including how oesophageal disorders like GERD, Barrett's oesophagus and oesophageal cancer affect and are affected by chronic liver disease, remains poorly understood.

AIMS

To review the relationship between oesophageal disorders and chronic liver disease, evaluating epidemiology, pathophysiology and therapeutic factors.

METHODS

We reviewed the literature on the relationship between oesophageal disorders and chronic liver disease, including cirrhosis, using the PubMed database RESULTS: Oesophageal disorders such as gastroesophageal reflux disease, Barrett's oesophagus, oesophageal cancer, oesophageal motor disorders and oesophageal candidiasis are prevalent among individuals with cirrhosis, exacerbating the burden of liver disease. These diseases have a multifaceted symptomatology and pathogenic basis, posing a significant challenge in cirrhotic patients that necessitates careful diagnosis and management. Additionally, therapies frequently used for these diseases, such as proton pump inhibitors, require careful consideration in cirrhotic patients due to potential adverse effects and altered pharmacokinetics. Managing oesophageal disorders in cirrhotic patients requires a cautious approach due to possible interactions with medications and the risk of adverse effects. Furthermore, symptoms associated with these conditions are often exacerbated by common interventions in patients with cirrhosis, such as band ligation for oesophageal varices.

CONCLUSIONS

Oesophageal disorders are common in cirrhosis and increase the disease burden. These conditions require careful management due to complex symptoms and treatment risks. Proton pump inhibitors and other therapies must be used cautiously, as cirrhosis interventions can worsen symptoms.

Complementary pneumatic dilations are an effective and safe treatment when laparoscopic myotomy fails: A 30-year experience at a single tertiary center

BACKGROUND

In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia, solving symptoms in most patients. Little is known about the fate of patients relapsing after LHM or their treatment. In this study, we aimed at evaluating the results of complementary pneumatic dilations (CPDs) after ineffective LHM.

METHODS

We evaluated the patients who underwent LHM with Dor fundoplication (LHD) from 1992 to 2022 and were submitted to CPD for persistent or recurrent symptoms. The patients were followed clinically and with manometry, barium swallow, and endoscopy when necessary. An Eckardt score (ES) of > 3 was used as threshold for failure.

RESULTS

Of 1420 patients undergoing LHD, 120 (8.4%) were considered failures and were offered CPD. Ten patients refused further treatment; in 5 CPD was not indicated for severe esophagitis; 1 patient had surgery for a misshaped fundoplication and 1 patient developed cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPDs (IQR, 1-3), at a median of 15 (IQR, 8-36) months after surgery, with 3.0- to 4.0-cm Rigiflex dilator (Boston Scientific, Massachusetts, USA). No perforations were recorded. Only 6 patients were lost to follow-up. Thus, 97 were followed for a median of 37 months (IQR, 6-112) after the last CPD: 70 (72%) were asymptomatic, whereas 27 (28%) had significant persistent dysphagia (ES > 3). The only differences between the 2 groups were the ES after surgery (P < .01) and the number of required CPD. Overall, the combination of LHD + CPD provided a satisfactory outcome in 96.5% of the patients.

CONCLUSION

CPDs represent an effective and safe option to treat patients after a failed LHD: when the postsurgery ES consistently remains high and the number of CPDs required to control symptoms exceeds 2, this may suggest the need for further invasive treatments.

Diagnostic and therapeutic strategies for achalasia of the cardia

The diagnosis of achalasia of the cardidia (AC) is primarily based on clinical symptoms, esophagographic findings, esophagodynamic examination, and upper gastrointestinal endoscopic findings. High resolution manometry is considered the gold standard for diagnosis. With the advan-cement of new technologies, the diagnostic methods for AC have become more diverse, and three-dimensional modeling may facilitate early detection of AC. The use of endoscopic functional intracavity imaging probe can enhance diagnostic accuracy. Common treatment options include endoscopic balloon dilation, laparoscopic Heller myotomy, and peroral endoscopic myotomy (POEM). POEM has emerged as the most widely utilized therapeutic approach currently, significantly improving the clinical success rate in treating AC. This article provides a comprehensive review on recent research progress in the diagnosis and treatment of AC.

Gastroesophageal reflux following peroral endoscopic myotomy for achalasia: Bumps in the road to success

Achalasia can significantly impair the quality of life. The clinical presentation typically includes dysphagia to both solids and liquids, chest pain, and regurgitation. Diagnosis can be delayed in patients with atypical presentations, and they might receive a wrong diagnosis, such as gastroesophageal reflux disease (GERD), owing to overlapping symptoms of both disorders. Although the cause of achalasia is poorly understood, its impact on the motility of the esophagus and gastroesophageal junction is well established. Several treatment modalities have been utilized, with the most common being surgical Heller myotomy with concomitant fundoplication and pneumatic balloon dilatation. Recently, peroral endoscopic myotomy (POEM) has gained popularity as an effective treatment for achalasia, despite a relatively high incidence of GERD occurring after treatment compared to other modalities. The magnitude of post-POEM GERD depends on its definition and is influenced by patient and procedure-related factors. The long-term sequelae of post-POEM GERD are yet to be determined, but it appears to have a benign course and is usually manageable with clinically available modalities. Identifying risk factors for post-POEM GERD and modifying the POEM procedure in selected patients may improve the overall success of this technique.

Unusual Achalasia Presentation Detected on 131 I SPECT/CT in a Papillary Thyroid Carcinoma Patient

ABSTRACT

Various factors leading to unexpected false-positive 131 I uptake have been extensively studied in patients with differentiated thyroid carcinoma. In this case, we present a patient who underwent achalasia surgery and subsequently exhibited abnormal 131 I uptake on SPECT/CT imaging. The patient was a known case of papillary thyroid carcinoma that suggested to 131 I therapy. 131 I SPECT/CT showed linear increased activity in the distended esophagus.

Complications related to third space endoscopic procedures

Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.

Novel scale for evaluating the therapeutic efficacy of per-oral endoscopic myotomy in achalasia

BACKGROUND

Symptom scales for achalasia after per-oral endoscopic myotomy (POEM) are lacking. This study aimed to propose a new scale based on the conventional Eckardt score (c-ES) and evaluate persistent symptoms that impair patients' quality of life (QOL) post-POEM.

METHODS

Dysphagia, regurgitation, and chest pain frequencies were assessed using a 6-point scale modified-ES (m-ES) after POEM, with "occasional" symptoms on the c-ES further subdivided into three-period categories on m-ES. Symptom severity was further evaluated using a 5-point scale ranging from 1 to 5 points, with a score ≥ 3 points defined as persistent symptoms impairing QOL. We analyzed the correlation between the m-ES and severity score, diagnostic performance of the m-ES for persistent symptoms, and overlaps between each residual symptom.

RESULTS

Overall, 536 patients (median follow-up period, 2.9 years) post-POEM were included in this multicenter study. Significant correlations were observed between the m-ES and severity scores for dysphagia (r = 0.67, p < 0.01), regurgitation (r = 0.73, p < 0.01), and chest pain (r = 0.85, p < 0.01). Twenty-six patients (4.9%) had persistent symptoms post-POEM, and 23 of them had m-ES-specific symptom frequency ≥ once a month, which was determined as the optimal frequency threshold for screening persistent symptoms. The total m-ES predicted persistent symptoms more accurately than the total c-ES (area under the curve: 0.95 vs. 0.79, p < 0.01). Furthermore, dysphagia and chest pain were the major residual symptoms post-POEM covering 91.4% of regurgitation.

CONCLUSIONS

The new post-POEM scale successfully evaluated the QOL-based patient symptom severities. Our study implied the possibility of a simpler scale using residual dysphagia and chest pain.

The Role of Viruses in the Pathogenesis of Immune-Mediated Gastro-Intestinal Diseases

Immune-mediated gastrointestinal (GI) diseases, including achalasia, celiac disease, and inflammatory bowel diseases, pose significant challenges in diagnosis and management due to their complex etiology and diverse clinical manifestations. While genetic predispositions and environmental factors have been extensively studied in the context of these conditions, the role of viral infections and virome dysbiosis remains a subject of growing interest. This review aims to elucidate the involvement of viral infections in the pathogenesis of immune-mediated GI diseases, focusing on achalasia and celiac disease, as well as the virome dysbiosis in IBD. Recent evidence suggests that viral pathogens, ranging from common respiratory viruses to enteroviruses and herpesviruses, may trigger or exacerbate achalasia and celiac disease by disrupting immune homeostasis in the GI tract. Furthermore, alterations in the microbiota and, specifically, in the virome composition and viral-host interactions have been implicated in perpetuating chronic intestinal inflammation in IBD. By synthesizing current knowledge on viral contributions to immune-mediated GI diseases, this review aims to provide insights into the complex interplay between viral infections, host genetics, and virome dysbiosis, shedding light on novel therapeutic strategies aimed at mitigating the burden of these debilitating conditions on patients' health and quality of life.

Feasibility and safety of peroral endoscopic myotomy with fundoplication in patients with achalasia: a systematic review and meta-analysis

Background

Achalasia can cause disabling symptoms that may substantially impair the quality of life. Peroral endoscopic myotomy (POEM) has shown promising results in the management of achalasia. In this meta-analysis we have evaluated the feasibility and safety of single-session POEM with fundoplication (POEM+F) in patients with achalasia.

Methods

We reviewed several databases from inception to July 08, 2022, to identify studies evaluating the feasibility and/or safety of single-session POEM+F for patients with achalasia. Our outcomes of interest included the technical success of POEM+F, adverse events, esophagitis and wrap integrity on follow-up upper endoscopy, total procedure time, and fundoplication time. Pooled rates with 95% confidence intervals (CI) for outcomes were calculated using a random effect model. Heterogeneity was assessed using the I 2 statistic.

Results

We included 4 studies with 90 patients. Pooled rates (95%CI) of technical success and adverse events were 92% (83-96%) and 5% (2-11%), respectively. Pooled rates (95%CI) of esophagitis and wrap integrity on follow-up upper endoscopy were 18% (11-30%) and 85% (43-98%) respectively. Pooled mean procedure time and fundoplication time were 113.2 (98.7-127.6) and 55.3 (43.7-66.8) min, respectively.

Conclusions

This meta-analysis demonstrates the feasibility and safety of POEM+F in patients with achalasia. More studies with long-term follow up are required to further validate these findings.

Achalasia phenotypes and prediction of peroral endoscopic myotomy outcomes using machine learning

OBJECTIVES

High-resolution manometry (HRM) and esophagography are used for achalasia diagnosis; however, achalasia phenotypes combining esophageal motility and morphology are unknown. Moreover, predicting treatment outcomes of peroral endoscopic myotomy (POEM) in treatment-naïve patients remains an unmet need.

METHODS

In this multicenter cohort study, we included 1824 treatment-naïve patients diagnosed with achalasia. In total, 1778 patients underwent POEM. Clustering by machine learning was conducted to identify achalasia phenotypes using patients' demographic data, including age, sex, disease duration, body mass index, and HRM/esophagography findings. Machine learning models were developed to predict persistent symptoms (Eckardt score ≥3) and reflux esophagitis (RE) (Los Angeles grades A-D) after POEM.

RESULTS

Machine learning identified three achalasia phenotypes: phenotype 1, type I achalasia with a dilated esophagus (n = 676; 37.0%); phenotype 2, type II achalasia with a dilated esophagus (n = 203; 11.1%); and phenotype 3, late-onset type I-III achalasia with a nondilated esophagus (n = 619, 33.9%). Types I and II achalasia in phenotypes 1 and 2 exhibited different clinical characteristics from those in phenotype 3, implying different pathophysiologies within the same HRM diagnosis. A predictive model for persistent symptoms exhibited an area under the curve of 0.70. Pre-POEM Eckardt score ≥6 was the greatest contributing factor for persistent symptoms. The area under the curve for post-POEM RE was 0.61.

CONCLUSION

Achalasia phenotypes combining esophageal motility and morphology indicated multiple disease pathophysiologies. Machine learning helped develop an optimal risk stratification model for persistent symptoms with novel insights into treatment resistance factors.

Correlation of Balloon Pressure Used for Pneumatic Dilatation in Achalasia with Manometric Findings and Factors Associated With the Need for Repeat Procedure

Achalasia is a chronic and rare disorder of esophageal motility. It is characterized by spastic or absent esophageal contractions and impairment of relaxation of the lower esophageal sphincter. Treatment modalities include smooth muscle-relaxing medications, botulinum toxin injections to lower the esophageal sphincter, pneumatic dilatation, and surgical interventions. Pneumatic dilatation is deemed to be an effective treatment option and is the most widely used non-surgical intervention. We designed this prospective study to look for any possible correlation between balloon pressure used in pneumatic dilatation, manometric findings, and patient characteristics. And to find any possible association between the need for repeat pneumatic dilatations and factors like gender, age, duration of symptoms, Eckardt score, daily retrosternal pain, manometric findings, and balloon pressures. Thirty-one patients with confirmed achalasia were enrolled in the study. All of these patients underwent pneumatic dilatation. Pearson's correlation coefficient was found to be 0.234 (p-value 0.23) between the required balloon pressure and integrated relaxation pressure (IRP). Six of these patients required repeat pneumatic dilatations. No statistically significant association was noted between the need for repeat intervention and gender, age over 40, age under 20, Eckardt score over 10, daily chest pain, duration of symptoms over two years, and IRP over 30 mmHg. In conclusion, it could be said that pneumatic dilatation does not carry a 100% success rate, and repeat sessions are needed in many of the patients with achalasia. So, long-term follow-up is crucial. Managing expectations and making a realistic plan with proper informational care is important at the beginning of treatment.

Gastroesophageal reflux after per-oral endoscopic myotomy: Management literature

In this editorial, we respond to a review article by Nabi et al, in which the authors discussed gastroesophageal reflux (GER) following peroral endoscopic myotomy (POEM). POEM is presently the primary therapeutic option for achalasia, which is both safe and effective. A few adverse effects were documented after POEM, including GER. The diagnostic criteria were not clear enough because approximately 60% of patients have a long acid exposure time, while only 10% experience reflux symptoms. Multiple predictors of high disease incidence have been identified, including old age, female sex, obesity, and a baseline lower esophageal sphincter pressure of less than 45 mmHg. Some technical steps during the procedure, such as a lengthy or full-thickness myotomy, may further enhance the risk. Proton pump inhibitors are currently the first line of treatment. Emerging voices are increasingly advocating for the routine combining of POEM with an endoscopic fundoplication method, such as peroral endoscopic fundoplication or transoral incisionless fundoplication. However, more research is necessary to determine the safety and effectiveness of these procedures in the long term for patients who have undergone them.

SHORT AND LONG-TERM RESULTS OF LAPAROSCOPIC ESOPHAGOCARDIOMYOTOMY WITH FUNDOPLICATION (HELLER-PINOTTI SURGERY) IN THE TREATMENT OF NON-ADVANCED ACHALASIA (MEGAESOPHAGUS)

BACKGROUND

Videolaparoscopic esophagocardiomyotomy with fundoplication has been a widely used technique for the treatment of achalasia. This study analyzes the safety and effectiveness of the technique in the treatment of non-advanced achalasia (megaesophagus) in a Brazilian federal university public hospital.

AIMS

To evaluate the short- and long-term results of videolaparoscopic treatment of non-advanced megaesophagus in a public university hospital in Brazil, employing the esophagocardiomyotomy technique with fundoplication.

METHODS

The medical records of 44 patients who underwent surgical treatment for non-advanced achalasia at the Clinical Hospital of Federal University of Uberlândia (UFU-MG), Minas Gerais, from January 2001 to July 2021 were analyzed. The following data were evaluated: gender, age, etiology, radiological classification of Rezende-Alves and Ferreira-Santos, immediate and late complications (mean follow-up of 31.4 months), need or not for conversion to open access, postoperative reflux, performance or not of endoscopic esophageal dilation in the preoperative period, postoperative mortality, frequency of pre and postoperative symptoms (persistent dysphagia, regurgitation, heartburn, vomiting, odynophagia, and weight loss), surgery time, hospital stay, duration of dysphagia, pre and postoperative weight, and Eckardt score.

RESULTS

Among the analyzed patients, 23 (52.3%) were male, and 21 (47.7%) were female, with a mean age of 50.8 years. No early complications were recorded and there were 27.2% cases of late gastroesophageal reflux. Postoperative weight gain was 81.8% and the success rate of surgery according to the Eckardt score was 84.1%.

CONCLUSIONS

Esophagocardiomyotomy with fundoplication is an effective and safe technique for the treatment of non-advanced achalasia.

Gastroesophageal reflux following per-oral endoscopic myotomy: Can we improve outcomes?

This editorial is an analysis the review article by Nabi et al recently published in this journal. Achalasia Cardia is a disease whose pathophysiology is still unclear. It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria. The end result is lower oesophageal sphincter spasm, loss of receptive relaxation, decreased oesophageal peristalsis, all leading on to varying degrees of dysphagia. The treatment of this condition is palliative in nature, performed by myotomy of the lower oesophagus either surgically or endoscopically. Gastroesophageal reflux disease (GERD) has been associated with the myotomy performed, particularly with the Peroral Endoscopic Myotomy (POEM) procedure. Nabi et al have provided an excellent overview of the latest developments in predicting, preventing, evaluating, and managing GERD subsequent to POEM. Based on this theme, this review article explores the concept of using histology of the oesophageal muscle layer, to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure. In the future, will a histology based algorithm available preoperatively, help modify the POEM procedure, thereby decreasing the incidence of GERD associated with POEM?