Introduction

Some achalasia patients exhibit esophageal contractile activity on follow-up after treatment, yet its importance remains unclear.

Aims & Methods

We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes. Patients with type I or II achalasia on baseline high-resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. The distal contractile integral (DCI) was calculated for the 10 supine swallows using the smart box tool with the isobaric contour set at 20 mmHg and median values were calculated. Contractility was defined on post-treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg∙s∙cm in accordance with CC v4.0¹. On FLIP, esophago-gastric junction (EGJ) opening was assessed applying the EGJ distensibility index (EGJ-DI) at the 60ml fill volume and measuring the maximum EGJ diameter that was achieved at the 60ml or 70ml fill volume. The classification of EGJ opening with FLIP Panometry used prespecified validated thresholds². For TBE, 200 mL of low-density barium sulfate were administered and the height of the barium column was measured vertically from the EGJ at 1 and 5 minutes.

Results

122 patients were included (mean age 48 ± 17 years, 50% female). At follow-up evaluation (median 13 months) after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM, with a median (IQR) DCI of 297 (183-545) mmHg∙s∙cm (median swallows with contractility: 80%). Patients with evidence of contractility (compared to those without contractility) more frequently had a pre-treatment diagnosis of type II achalasia (84% vs 57%, p=0.001) and more frequently had a normal/borderline-normal EGJ opening (92% vs 66%, p<0.001). 14 patients (23%) had spastic contractility (≥20% swallows with DL <4.5 s) and it was not associated with higher TBE column heights at 1 minute (3 vs 4 cm, p=0.422) or 5 minutes (0 vs 0 cm, p=0.506) when compared to non-spastic contractility. In the subgroup of patients with post-treatment integrated relaxation pressure <15mmHg and normal EGJ opening on FLIP (n=53), those with contractility had lower median column heights on TBE at 1 minute (4 vs 7 cm, p=0.002) and 5 minutes (0 vs 5 cm, p=0.001). These patients also had higher median FLIP 60 ml pressures (29 vs 23 mmHg, p=0.024). Eckardt scores were not significantly different across groups.

	Entire cohort		Normal EGJ subgroup
	No contractility (n=61)	Contractility present (n=61)	No contractility (n=20)	Contractility present (n=33)
IRP, mmHg, median (IQR)	13 (10-20)	12 (9-16)	11 (8-13)	10 (7-14)
60ml pressure, mmHg, median (IQR)	25 (21-31)	29 (24-33)​​​​​​	23 (20-28)	29 (25-32)
EGJ opening classification normal + borderline-normal	40 (66)	56 (92)	-	-
EGJ opening classification reduced + borderline-reduced	21 (34)	5 (8)	-	-
1-minute column height, cm, median (IQR)	8 (5-12)	4 (0-8)	7 (5-10)	4 (0-7)
5-minute column height, cm, median (IQR)	6 (2-9)	0 (0-4)	5 (2-7)	0 (0-3)
Esophageal width, cm (IQR)	2.9 (2.0-3.5)	2.1 (1.7-2.7)	2.6 (1.6-3.1)	1.8 (1.7-2.3)
Eckardt score, median (IQR)	3 (1-4)	2 (1-3)	2 (1-4)	2 (1-4)

Comparisons with significant (p<0.05) differences are marked in bold.

Conclusion

Esophageal body contractility appears to contribute to improved esophageal emptying after treatment of non-spastic achalasia. Contractility more frequently occurs in type II achalasia and seems facilitated if adequate EGJ opening is achieved after treatment. Avoidance of unnecessary extended myotomy may help preserve potential for contractility and improved outcomes in these patients.

References

1. Yadlapati R, Kahrilas PJ, Fox MR, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0(©). Neurogastroenterol Motil 2021;33:e14058.
2. Carlson DA, Prescott JE, Baumann AJ, et al. Validation of Clinically Relevant Thresholds of Esophagogastric Junction Obstruction Using FLIP Panometry. Clin Gastroenterol Hepatol 2022;20:e1250–e1262

Disclosure

John E. Pandolfino and Peter J. Kahrilas (with Northwestern University) hold shared intellectual property rights and ownership surrounding FLIP Panometry systems, methods, and apparatus with Medtronic, Inc; Dustin A. Carlson is a speaker for Medtronic, and a consultant for Medtronic and Phathom Pharmaceuticals, and shares a licensing agreement with Medtronic. Peter J. Kahrilas has consulted for AstraZeneca, Ironwood, Reckitt, and Johnson & Johnson; and John E. Pandolfino has consulted for Sandhill Scientific/Diversatek, Medtronic, Torax, and Ironwood, has been a speaker for Sandhill Scientific/Diversatek, Takeda, Astra Zeneca, Medtronic, and Torax, has received grant support from Sandhill Scientific/Diversatek, and owns a patent and license with Medtronic. Edoardo Vespa, Domenico A. Farina and Andree H. Koop have no disclosures.

Introduction

Peroral endoscopic myotomy (POEM) may result in a distended distal esophagus, referred to as a blown-out myotomy (BOM). It has been suggested that BOM may have functional and symptomatic consequences. The aim of this study was to investigate the prevalence, risk factors and associated symptoms of BOM after achalasia treatment using a clinical trial dataset (POEMA trial).

Aims & Methods

We analyzed data of newly diagnosed symptomatic achalasia patients (based on an Eckardt greater than 3) in our center who participated in a previous randomized controlled trial in which they were randomly allocated to undergo treatment with POEM or pneumatic dilation (PD). Follow-up was planned at 3 months, 1, 2 and 5 years after treatment and included an esophagram, endoscopy, HRM and symptom questionnaires. We defined a BOM as a >50% increase in esophageal diameter at its widest point in the distal esophagus between the lower esophageal sphincter and 5 cm above.

Results

In total 74 patients were treated in our center, of which 5-year follow-up data was available in 55 patients (32 (58%) patients randomized to POEM, 23 (42%) PD). During the 5-year follow-up a part of the patients received retreatment which resulted in 15 (27%) patients that were treated with PD only and 40 (73%) patients treated with POEM or PD + POEM. In the group initially treated with POEM the incidence of BOM increased from 11.5% (4/38) at three months, 21.1% (8/38) at 1-year, 27.8% (10/36) at 2-years and 31.3% (10/32). A BOM was seen in none of the patients treated with PD alone and 32.5% of the patients ever treated with POEM at 5-year follow-up (p=0.011). There were no differences in baseline LES-resting pressure (25.8 (21.8-34.0) mmHg vs 36.0 (26.4-46.3) mmHg, p=0.168) and baseline IRP-4 (24.7 (17.8-36.5) mmHg vs 31.0 (21.7-38.7) mmHg, p=0.240) between patients ever treated with POEM with or without a BOM. Achalasia subtype type did seem to be a risk factor for the occurrence of a BOM in our cohort, as BOM occurred in 25% (2/8) of type 1, 27% (7/26) of type II and 67% (4/6) of type III achalasia (p=0.152). Patients that developed a BOM had higher total Eckardt score and Eckardt regurgitation component compared to patients that underwent POEM without BOM development (3 (2.75-3.25) vs 2 (1.75-3) p=0.032) and (1 (0.75-1 vs 0 (0-1) p=0.041). The barium column surface (barium height * width) was not significantly different at 1 minute (12.2 (8.4-19.1) cm² vs 10.5 (3.0-17.6) cm², p=0.345) or at 5 minutes (10.8 (2.7-18.9) cm² vs 7.2 (0-12.8) cm², p=0.197) in patients with or without a BOM. In addition, at 5-year follow-up no significant difference was seen in IRP-4 (13.4 (9.1-18.8) mmHg vs 12.1 (8.5-16.7) mmHg, p=0.377) and LES-resting rate (18.1 (14.3-26.0) mmHg vs 22.3 (13.7-29.8) mmHg, p=0.642) in patients with or without a BOM. POEM patients more often report reflux symptoms (based on GERDQ > 8) when a BOM is present compared to when no BOM is present (85% (11/13) vs 46% (2/16), p=0.023)). BOM did not have an effect on presence of reflux esophagitis (54% (7/13) vs 41% (11/27), p=0.329) or PPI use (54% (7/13) vs 44% (12/27), p=0.413). Acid exposure time (measured at 1-year follow-up) was significantly higher in patients with a BOM compared to no BOM ((24.5% (8-47)) vs 6% (1.2-18.7), p=0.027).

Conclusion

a BOM was seen in one third of patients treated with POEM regardless of achalasia subtype, resulting in a higher acid exposure, more reflux symptoms and symptoms of regurgitation.

Disclosure

PF received consultancy fees from Olympus and Cook Endoscopy.
JEP received research funding from National Institutes of Health National Institute of Diabetes and Digestive and Kidney Disease, and declares the following financial relationships with a commercial interest: consulting for Medtronic, ethicon, diversatek, Ironwood, Phathom, and Neurogastrx; patent held or filed (FLIP-AI) for Medtronic; and speaking and teaching for Medtronic and ethicon.
AJB received research funding from Nutricia, Dr Falk Pharma, Thelial, SST and Bayer and received speaker or consulting fees from Laborie, Medtronic, Dr Falk Pharma, Alimentiv, Sanofi/Regeneron, and AstraZeneca.
All other authors declare no competing interests.

Introduction

Treatment of non-obstructive esophageal dysphagia (NOD) should consider not only the primary condition, but also its impact on patients’ daily function, their perception and surgical risk. Between surgical, endoscopic, and medical therapies, there is a wide range of choices, most without well-established indications or outcomes.

Aims & Methods

This is an ongoing prospective multicentric study to evaluate the real-life approach to NOD in 7 centers, by comparing the efficacy of different treatments [per-oral endoscopic myotomy (POEM), botulinic toxin (BT), pneumatic dilation (PD), optimization of proton-pump inhibitors (PPI) and expectant], through the Eckardt, EuroQol-5D (TTO and VAS) and PROMIS GI Disrupted Swallowing (PDS) scores.

Results

According to Chicago V4, it included 97 esophagogastric junction (EGJ) outflow disorders, 24 spastic motility disorders, 38 hypomotile disorders and 91 dysphagia with normal manometry. Fifty-seven (22.8%) patients were submitted to therapy.
Forty-three (44.3%) patients with EGJ outflow disorders were treated (31 POEM, 5 BT, 2 PD, 1 surgical and 4 medical). In contrast to untreated, treated patients showed better differences in Eckardt, PDS and EuroQol-5D VAS scores (p-values <0.005) after 6 months.
PPI was introduced and/or optimized in five (13.2%) patients with hypomotile disorders. There were no differences in Eckardt, EuroQol-5D and PDS at 6-months in treated or untreated patients.
Three (12.5%) patients with spastic motility disorders were treated (2 BT and 1 calcium-channel blocker). Both treated and untreated showed no differences in Eckardt or EuroQol-5D scores at 6 months.
Regarding dysphagic patients with normal manometry, medical treatments were optimized in 6 patients (6.6%), without any differences in Eckardt and EuroQol-5D scores at 6-months. Interestingly, the PDS showed a better difference at 6 months in untreated patients (p-value <0.001).

Conclusion

Apart from EGD outflow disorders, which have well-established treatment options, real-life approach of NOD is heterogeneous and showed no clear benefit. To improve clinical results, specialized clinics must be created.

Introduction

Limited studies have described changes in esophageal manometry patterns after achalasia treatment.

Aims & Methods

Aims: To describe manometric changes and determine factors associated with post-treatment peristalsis return.
Methods: Ninety-one consecutive patients with achalasia [60F, age 47±16 years, 34 with type I, 46 with type II, 11 with type III] were included in the study and underwent high-resolution esophageal manometry (Manoscan, MN, USA) in the upright position before and 1-3 months after treatment [pneumatic balloon dilation (n=60) or per-oral endoscopic myotomy (n=31)]. Post-treatment peristalsis was classified as normal, weak, and premature contraction according to the Chicago classification v.4.0. Clinical characteristics were recorded.

Results

	A 1	A 2	A 3	A 4	A 5	A 6	A 7	A 8	A 9
Age	58	17	56	59	36	65	60	49	37
Gender	F	F	M	F	F	F	F	F	F
Pre-treatment type	1	2	2	2	1	1	2/3	2	2/3
Procedure	PD	POEM	POEM	POEM	PD	PD	POEM	PD	POEM
Pre-treatment Median IRP	39.45	22.55	23.45	35.15	20.85	25.6	8.5	35.85	33.35
Post-treatment Median IRP	12.35	6.25	29.15	50	16.95	17.1	10.45*	4.8	17.9
Number of peristalsis	10/10	6/10	3/10	3/10	5/10	1/10	4/10	5/10	3/10
Post treatment Eckardt score	0	0	0	0	2	0	1	0	7
Global symptom improvement	95%	100%	80%	100%	60%	80%	90%	100%	80%

^* High intragastric pressure

Nine patients (9.9%) had post-treatment peristalsis return with average prevalence of 5(2-5) times in 10 wet swallows. Of the 40 peristalsis returns, there was no instances of peristalsis with normal contraction vigor (distal contractile integral, DCI 450-8000 mmHg•s•cm) and normal distal latency (>4.5s). 17(42.5%) returns had normal contraction vigor with premature contraction and 23(57.5%) had weak contraction. Of these weak contractions, only 1 contraction had a normal distal latency, while 22 contractions had a short distal latency. The patients with post-treatment peristalsis had a median Eckardt score of 0 (0-1) with a median global symptom improvement of 85(80-96%). Age, gender, BMI, achalasia subtype, treatment type, baseline basal lower esophageal sphincter pressure, baseline median IRP, and treatment outcomes were not significantly different between patients with and without peristalsis return.

Conclusion

The study found that post-treatment peristalsis recovery with weak and premature contractions occurred in 10% of patients with achalasia and was not significantly associated with clinical or manometric factors or short-term treatment outcomes.

References

-

Introduction

Outcome after treatment of achalasia is usually assessed by the Eckardt score (ES). The timed barium esophagogram (TBE) is used to objectively assess esophageal clearance after treatment. High-resolution manometry with impedancemetry (HRiM) provides information on esophageal clearance of liquids in addition to motility parameters. The aim of this study was to compare esophageal clearance determined by HRiM and TBE in patients with achalasia treated by POEM.

Aims & Methods

Consecutive patients treated with POEM had pre and post-POEM assessment with ES, TBE, and HRiM. Treatment failure was defined by an ES > 3 at 3 months post-POEM. Incomplete esophageal clearance (IEC) was defined by the presence of an esophageal stasis > 2 cm at 5 minutes in HRiM and/or TBE. All of the data available pre and post-POEM at 3 months was pooled for analysis. The correlation between ES, TBE and HRiM was evaluated by Spearman's method.

Results

Fifty patients with a median age of 65 years (23-84) were included in this study (85% with type 2 achalasia). The clinical response rate at 3 months was 94%. TBEM/HRiM results were available in (29/33) pre-POEM patients and (43/46) post-POEM patients at 3 months. Overall, an IEC was found in 91% on TBE and in 50.8% on HRiM. The correlation between the ES and IEC in HRiM and TBE were respectively 0.66 and 0.31. The correlation between esophageal clearance values between TBE and HRIM was low (r=0.375). At 3 months after POEM, IEC was present in 90.7% and 21.7% for TBE and HRiM, respectively (p<0.001). In univariate and multivariate analysis, only IEC in HRiM was significantly associated with ES > 3 (RR = 17.0 (p < 0.001)). The HRiM AUC was 0.872 vs. 0.707 for the TBE (p<0.001). The diagnostic performance of HRiM to predict an ES > 3 was Se: 85%; Sp: 77%; PPV: 74%; NPV: 87% vs. Se: 95%; Sp: 11%; PPV: 42%; NPV: 83% for the TBE. Data at one year will be available for the presentation.

Conclusion

In achalasia, the evaluation of esophageal clearance by HRiM is better correlated with ES than TBE and may be a relevant criterion for pre and post-therapeutic evaluation. Additional studies are underway to validate the relevance of this parameter more specifically in the evaluation of treatments for esophageal achalasia.

References

1. Lin Z, Nicodème F, Lin CY, Mogni B, Friesen L, Kahrilas PJ, et al. Parameters for quantifying bolus retention with high-resolution impedance manometry. Neurogastroenterol Motil. 2014 Jul;26(7):929–36.
2. Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout AJPM. Assessment of oesophageal emptying in achalasia patients by intraluminal impedance monitoring. Neurogastroenterol Motil. 2006 Nov;18(11):971–7.
3. Cho YK, Lipowska AM, Nicodème F, Teitelbaum EN, Johnston ER, Gawron A, et al. Assessing Bolus Retention in Achalasia using High Resolution Manometry with Impedance: A Comparator Study with Timed Barium Esophagram. 2015;15.
4. de Oliveira JM, Birgisson S, Doinoff C, Einstein D, Herts B, Davros W, et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. Am J Roentgenol. 1997 Aug;169(2):473–9.
5. Kostic S, Andersson M, Hellström M, Lönroth H, Lundell L. Timed barium esophagogram in the assessment of patients with achalasia: Reproducibility and observer variation. Dis Esophagus. 2005 Jun 1;18(2):96–103.

Introduction

Esophageal Achalasia (EA) is a rare esophageal motility disorder, characterized by impaired peristalsis and incomplete relaxation of the Lower Esophageal Sphincter (LES) in response to swallowing​​​​​. Key symptoms of the disease include dysphagia, food regurgitation, and retrosternal pain, significantly impacting the quality of life (QoL) and often leading patients to restrict their food intake. Consequently, EA patients often adopt self-managed dietary practices that may result in nutritional imbalances and deficiencies, given the lack of specific dietary guidelines.

Aims & Methods

This retrospective study aimed to describe and evaluate the dietary patterns, eating habits, and nutritional status of achalasic patients. Additionally, the secondary aim was to explore potential associations between food rheology and symptomatology. Patients with a manometric diagnosis of EA were recruited from our outpatient gastrointestinal pathophysiology center. Disease severity was assessed with Eckardt Symptoms Score (ESS), symptoms were evaluated with Modular Questionnaire Roma IV and QoL with the MD Anderson Dysphagia Inventory (MDADI). The MDADI outcomes were stratified into severe, moderate, mild and not perceived disability. Patients also filled out a food diary for 15 days, recording ingested food for each meal and symptoms onset. Estimated caloric intake and macronutrient composition were compared to those recommended by the Italian Society of Human Nutrition (SINU).

Results

Forty-three achalasic patients were included (M 24, F 19, mean age 56.7 +- 15.8 yrs). The median BMI was 23.7 (18.8-32.2), 34 patients (79%) had an active disease (ESS ≥ 3). Most patients reported mild to moderate disability (respectively 42% and 35%), while 21% reported severe disability and 2% perceived no disability. Disease activity, measured by ESS, strongly correlated with perceived disability (r= 0.59; p <0.0001), while no significant correlation was found between ESS and BMI. The diary analysis showed a mean caloric intake of 1572±373 kcal versus the estimated needs of 2293,71±374 kcal based on anthropometric parameters and physical activity, resulting in a mean caloric deficit of 720 ± 416 kcal (p<0.0001). Macronutrient analysis also reported an unbalanced distribution: carbohydrates 43.3%±7.3 vs recommended 55-59%, protein 18.2%±4.5 vs 15-18%, total fat 37.6%±7.7 vs 26–27% and fibre 14g±5.2 vs 25-30g. Solid food caused significantly more symptoms than semiliquid and liquid ones: dysphagia (35.5% vs 3.5% vs 5.7%, p<0.0001), chest pain (10% vs 12.1% vs 0.2%, p<0.0001), regurgitation (8.9% vs 1.4% vs 1.9%, p=0.001), cough (5% vs 0.2% vs 0.6%, p=0.0002). Bread, pasta, and pizza (50-60%), fresh fruit (44%), lean meat (39.5%), crackers, snacks, and vegetables (30-35%) were the most commonly reported triggers of dysphagia. Additionally, 60% of patients reported worsened symptoms with cold foods, while 53% reported improvement with hot foods.

Conclusion

This study underscores the significant impact of EA on QoL, influenced by disease activity. Achalasic patients tend to modify their diets to minimize symptoms, favoring easily swallowable soft and fatty foods while reducing intake of solid foods rich in carbohydrates and fiber. Thus, comprehensive nutritional assessment is strongly recommended for EA patients to mitigate dietary imbalances and manage possible deficiencies promptly.