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

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

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

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Introduction

Peroral endoscopic myotomy (POEM) has become a standard endoscopic treatment for patients with achalasia, with many studies reporting on its long-term effectiveness. However, the impact of a patient’s previous surgical history on the long-term outcomes of POEM remains unknown.

Aims & Methods

This study aims to compare the long-term efficacy of POEM in achalasia patients with and without prior surgical interventions. A single center, retrospective review was conducted on achalasia patients who underwent POEM between January 2016 to December 2020. Clinical, demographic, radiographic, endoscopic, and manometric data were collected. Patients with less than two years of follow-up without noted failure were excluded. The analysis compared outcomes between first-time POEM patients (naïve POEM) and those undergoing POEM following failed surgical treatments (redo POEM). The primary outcome was the clinical success rate, defined as an Eckardt Score of 3 or less at final follow-up and no need for additional interventions. Secondary endpoints included the prevalance of postoperative gastroesophageal reflux disesase (GORD), the necessity for acid suppression medications, and additional interventions for achalasia.

Results

Data were collected on 47 naïve POEM and 26 redo POEM patients. After excluding 17 naïve POEM patients and 8 redo POEM patients who did not meet the criteria for long-term follow-up, a total of 30 naïve POEM patients and 18 redo POEM patients were analyzed. In the redo POEM group, 77.8% (14/18) of the patients underwent Heller myotomy with Dor fundoplication, while the surgical details for the remaining patients were unknown. The median length of symptoms was 5 (IQR 3-10) years for naïve patients and 6 (IQR 1.2-17.5) years for redo patients (p=0.29). According to the Chicago classification v4.0, the achalasia subtypes in the naïve POEM group were Type I in 9 patients (30%), Type II in 12 (40%), Type III in 3 (10%), and other types in 6 (20%). For the redo POEM group, subtypes were Type I in 9 patients (50%), Type III in 2 (11.1%), and unspecified in 7 (38.9%). Barium esophagram revealed no significant differences in the maximum diameter between the groups (naïve POEM 45.8 ± 21.4 mm vs. redo POEM 44.9 ± 15.4 mm, p=0.89). Long-term success rates were 76.7% (23/30) in naïve POEM and 83.3% (15/18) in redo POEM, with no significant difference between the groups (p=0.72). Postoperative GORD was noted in 63.3% (19/30) in the naïve POEM versus 67% (12/18) in the redo POEM (p=0.06), with newly prescribed acid suppression medication in 23.3% (7/18) and 55.6% (10/18), respectively (p=0.02). Additional interventions for achalasia were required in 10% (3/30) in the naïve POEM versus 11.1% (2/18) in the redo POEM, with no significant difference between the groups (p=1.0). In the naïve POEM group, one patient required a second POEM, another was hospitalized due to achalasia recurrence, and a third underwent Heller myotomy with Dor fundoplication. In the redo POEM group, one patient underwent endoscopic balloon dilatation, and another required esophagectomy.

Conclusion

POEM is an effective long-term treatment for achalasia, demonstrating similar success rates in patients undergoing either their first or redo POEM procedures. The overall efficacy and safety profiles support POEM as a recommended treatment for managing achalasia regardless of prior surgical treatment failures.

Introduction

Peroral Endoscopic Myotomy (POEM) is an effective treatment for esophageal motility disorders, particularly achalasia. POEM also demonstrated a good safety and efficacy profile in patients with prior treatment failure (PTF). However, long-term data of POEM for this selective group have been underexplored. This study aims to compare long-term outcomes of POEM in patients with and without PTF.

Aims & Methods

This is a retrospective analysis of a prospectively maintained cohort of patients who underwent POEM for esophageal motility disorders at a single high-volume center between March 2012 and March 2024. Patients who had completed at least 6 months of follow-up were included. Baseline data included demographics, type of esophageal motility disorder, esophageal shape, and pre-POEM Eckardt score (ES). Procedural data included procedural time, adverse events and length of hospitalization. Follow-up data included clinical failure (defined as ES ≥ 4), gastroesophageal reflux disease (GERD) symptoms, erosive esophagitis > B grade at esophagogastroduodenoscopy (EGD) and acid exposure time (AET) > 6% at pH-impedance monitoring. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression to identify factors associated with clinical failure. A 1:1 PSM without replacement was performed, and weighted regression analyses were used to evaluate outcomes.

Results

595 patients underwent POEM during the study period. A total of 564 patients (median age 57 years, 57.3% male) with at least 6 months of follow-up after POEM for esophageal motility disorders (12.7% achalasia I, 76.6% achalasia II, 6.4% achalasia III, 4.2% other non-achalasia disorders) were included in the analysis. One-hundred eight (19.1%) patients had undergone previous treatments (37% Heller myotomy, 39% pneumatic balloon dilation, 15% POEM, 9% Botulinum toxin injection). No significant difference was observed in terms of median procedural time (70 minutes (IQR 55;85) vs 71 minutes (IQR 56;86)) and adverse events (4.6% vs 1.8%) between primary POEM patients and those with PTF (P = ns). Globally, over a median follow-up of 36 months (range 6-60), 72 (12.7%) clinical failures were reported. After matching, 130 patients (65 per group) were analyzed for clinical failure. In the matched cohort, clinical failure occurred more frequently in PTF patients compared to controls (24.6% vs 10.8%). In a weighted Cox regression model, PTF was associated with a significantly higher risk of clinical failure (HR 2.20; 95% CI 1.05–5.36; p = 0.04). Regarding reflux-related outcomes, no statistically significant differences were observed between groups after matching: clinical reflux (38.2% vs 30.3%, p = 0.41), severe esophagitis (34.2% vs 24.7%, p = 0.29), and pathological AET >6% (45.9% vs 45.9%, p = 1.00).

Conclusion

POEM remains a highly effective, safe and durable treatment option for esophageal motility disorders with optimal long-term outcomes. However, patients with PTF undergoing POEM had a significantly higher risk of clinical failure. These findings highlight the need for closer monitoring and potential enhanced interventions for these patients.