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.
