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

Timed barium esophagogram (TBE) is widely used to evaluate esophageal clearance (EC) after peroral endoscopic myotomy (POEM) in achalasia. However, high-resolution impedance manometry (HRiM) offers a dynamic, radiation-free alternative, potentially more accurate and reflective of true esophageal function.

Aims & Methods

To compare EC assessed by HRiM (EC_HRiM) and TBE (EC_TBE) after POEM for achalasia, and to evaluate their diagnostic performance, reproducibility, and predictive value for long-term clinical success, with external validation.
We conducted a monocentric prospective study between October 2020 and September 2023. Patients undergoing POEM were assessed pre- and post-procedure using Eckardt score, HRiM, and TBE. Treatment failure was defined by an Eckardt score >3 at 12 months. EC impairment was defined as a residual column height >5 cm at 5 minutes. In parallel, we validated our findings in an independent cohort. Statistical correlations and diagnostic performance were analyzed using Spearman, Pearson, ICC, and ROC curve analyses.

Results

In the primary cohort (n=104; 65% male; median age 62; 75% with type II achalasia; 30% had prior treatment, mainly dilation), 97 patients completed the 12-month follow-up, with a POEM success rate of 90%. EC significantly improved post-POEM on both modalities (HRiM: −8.9 cm; TBE: −4.9 cm; p<0.001). Interobserver reproducibility of EC measurement was higher for HRiM (ICC =0.98) than for TBE (ICC=0.93) (p<0.001). EC_HRiM correlated more strongly with clinical outcomes (Spearman r = 0.68) than EC_TBE (r = 0.37). In univariate analysis, significant predictors of failure were EC_HRiM (p<0.001), 3-month Eckardt score (p<0.001), and EC_TBE (p<0.001). The most discriminative thresholds were EC_HRiM < 0 cm and EC_TBE < 9 cm. Diagnostic performance of HRiM at this threshold was: Se = 66%, Sp = 82%, PPV = 30%, NPV = 95%. For TBE, the same values were: Se = 100%, Sp = 59%, PPV = 19%, NPV = 100%.
In the external validation cohort (median age: 66.5 years; 55.7% male; 50.8% with type II achalasia), the 12-month failure rate was 14.8%. Diagnostic performance of HRiM for predicting clinical FAILURE in this cohort showed: sensitivity 55.6%, specificity 82.7%, PPV 35.7%, and NPV 91.5%, confirming its utility in real-world settings.

Conclusion

HRiM is a reliable, reproducible tool for assessment of esophageal clearance post-POEM and shows stronger correlation with clinical outcomes than TBE. Its predictive value was confirmed in an external validation cohort, supporting its potential as a new standard in achalasia management.

Disclosure

None

Introduction

High-resolution manometry (HRM) is an invasive and technically demanding procedure. Despite the existence of a well-established standard protocol, technically imperfect studies are common and may reduce diagnostic certainty.

Aims & Methods

The aim of this study was to develop a practical and feasible quality score for HRM that correlates the technical quality of the study with the reliability of the diagnosis.
A 10-point quality score was developed based on seven quality indicators: catheter passage across the esophagogastric junction (EGJ), evaluable resting pressures, valid wet swallows, completion of multiple rapid swallows (MRS) and rapid drink challenge (RDC), upright swallows, and absence of artifacts.
The obtained score was used to classify manometric studies into five diagnostic reliability categories: 1) 0–2 points: Uninterpretable manometry, 2) 3–4 points: Deficient manometry with low diagnostic reliability, 3) 5–6 points: Deficient manometry with moderate diagnostic reliability, 4) 7–8 points: Deficient manometry with high diagnostic reliability, 5) 9–10 points: Excellent manometry allowing a certain diagnosis
An initial exploratory evaluation was conducted by two observers (one high-experience, one low-experience observer) who prospectively reviewed 90 HRM studies. A revised version of the score was subsequently implemented and applied in a second evaluation round. In addition to assigning a final quality score, each observer provided the manometric diagnosis of each revised HRM according to Chicago IV classification (CC4.0) and rated the diagnostic confidence level (high, medium, low reliability). In case of disagreement, a third expert adjudicated.

Results

Initial agreement on quality score classification was reached in 30 cases (Cohen’s kappa=0.274) using the original score, improving to 67 out of 90 studies when the revised version was used (Cohen’s kappa=0.718). The main sources of disagreement in the remaining 23 studies were the number of valid swallows (12 studies) and the presence of intragastric pressurization (8 studies). Further evaluation by the expert supported the high-experience observer in 13 cases and the low-experience observer in 5; no consensus was reached in five studies. Overall, 85% of the studies were scored as high-quality studies (score≥7). Diagnostic confidence was rated as high in 86 % of the cases, medium in 14 %, and no cases were rated as low confidence.
There was a good association between quality score and diagnostic confidence among the observers. Hence, 90 % of the studies rated as high-quality studies had a high confidence rate in the diagnostic accuracy, and 62 % of the low-quality studies had a medium level of confidence (p<0.001).
Despite some uncertainty, the two observers agreed on diagnosis in 82 studies (disagreement occurred in two low-quality studies and six high-quality studies). Following expert adjudication, full consensus in diagnosis was reached in all 90 studies. Notably, most of the diagnoses were normal motility or ineffective esophageal motility (86 %), while only 10 % were classified as major motility disorders. Four patients had inconclusive diagnoses according to CC4.0 (two low-quality and two high-quality studies).

Conclusion

A new developed quality score appears to be a valuable tool for assessing HRM study quality and supporting final diagnostic accuracy. Ongoing larger studies aim to determine its potential in clinical practice.

Introduction

Achalasia is a primary motility disorder, which presented by dysphagia. The most effective treatment of the disease is surgical (peroral myotomy or laparoscopic myotomy). However, there are few studies which assess the changes in esophageal motility after surgery.

Aims & Methods

The aim of our study was evaluating the changes in esophageal manometry in patients with achalasia after peroral endoscopic myotomy (POEM).
Subjects and methods: 43 patients with achalasia were consequently observed before and 1 year after POEM. Females predominated (28 subjects). All patients examined endoscopically, then high resolution manometry (HRM) was performed by Solar™ GI (MMS/Laborie, Netherland). Achalasia was defined as described in Chicago Classification 4.0. Eight patients had I type of achalasia, 24 – II type and 11 – III type.

Results

The median Eckardt score was 7 on the start and 2 – after POEM in 35 patients (group A). However, 8 patients were dissatisfied with the surgery (4 pts with II type achalasia and 4 – III type). They continued to suffer from dysphagia and/or noncardiac chest pain (group B).
According to HRM the mean resting pressure of LES in group A reduced 2 folds from 39,1±2,7 mmHg to 18,9±1,4 mmHg. Also we revealed the dramatic decrease in integrated residual pressure (IRP) from 22,8±0,7 mmHg to 9,8±0,6 mmHg and DCI: from 1865,5±286,9 to 128,2±53,8. In a group B the mean resting pressure of LES reduced from 48,8±2,4 mmHg to 33,6±2,4 mmHg. The integrated residual pressure (IRP) decreased from 22,8±0,7 mmHg to 15,01±0,6 mmHg and DCI: from 2999,6±417,6 to 1038,1±107,7.
Even though, we didn’t observed the peristaltic waves in two groups before and after POEM as a normal manometric criteria: the consistent contraction of upper part of esophagus and then lower part of esophagus. Besides, HRM evaluated persisting spastic contraction in the middle and lower part of esophagus in patients with type III achalasia from group B. Two patients from group B with type II had good results in esophageal manometry.

Conclusion

The reduction of resting pressure, integrated resting pressure and distal contractile interval in several times can be accepted as criteria of POEM effectiveness. Besides, in patients with III type of achalasia we must assess the absence of spastic contraction as additional criteria of POEM satisfaction.

Introduction

According to Chicago Classification version 4.0 a diagnosis of absent contractility and esophagogastric junction outflow obstruction (EGJOO) during high-resolution manometry (HRM), are both considered inconclusive diagnoses of achalasia, thus requiring presence of relevant symptoms such as dysphagia, and additional supportive tests, including timed barium esophagram (TBE) or functional lumen imaging probe (FLIP), in order to confirm the presence of achalasia and treat accordingly.

Aims & Methods

Aim: To evaluate the clinical utility of TBE and FLIP to further confirm diagnosis of achalasia in patients with inconclusive diagnosis of achalasia per HRM.
Methods: We conducted a retrospective study in patients referred for evaluation of dysphagia from December 2021 until December 2022 . Patients completed an upper gastrointestinal endoscopy and HRM per Chicago classification v.4.0. Those patients with an inconclusive diagnosis of achalasia during HRM, either absent contractility or EGJOO, followed by additional assessment with TBE and/or FLIP were included. Patients with anatomic lesions of the esophagus (i.e Schatzki ring, esophageal diverticula), esophageal surgery and chest radiotherapy were excluded.

Results

A total of 101 consecutive patients were referred for evaluation and 29 patients were included for analysis. Median age was 71 (p=0.58) and 65.51% of the patients were female (p=0.1). Of the 29 patients who had an HRM diagnosis of inconclusive achalasia, 55.17 % had absent contractility and 44.82% were diagnosed with EGJOO. After completing a TBE, 28.68 % of those patients had an abnormal result (delayed TBE). There was a significant correlation between an inconclusive diagnosis of achalasia per HRM and delayed TBE (OR 3.83 95 % CI [1.36-10.79], p=0.001). Furthermore, diagnosis of EGJOO was significantly correlated with esophageal stasis and delayed TBE (p=0.025). Additionally, we found a significant correlation between inconclusive diagnosis of achalasia and confirmation of achalasia with FLIP in one patient (p=0.0008). All patients were referred for achalasia-treatments.

Conclusion

Patients classified as inconclusive diagnosis of achalasia during HRM benefit from additional supportive testing with TBE to confirm the presence of achalasia, therefore, provide treatment.

Introduction

Based on the Chicago classification, HREM diagnosis is classically based on metrics obtained with wet swallows carried out in the supine position. However, both patients and physicians often feel that this is not a physiological position to conduct the test as it may not translate to the real world experience. With the patient in the upright/sitting position, the test would more closely simulate real-life behaviour and may be safer for elderly patients at risk of aspiration.

Aims & Methods

In an Asian tertiary centre, a total of 104 patients had undergone high resolution esophageal manometry (HREM) with retrospective data analysis comparing both conventional supine position with the upright position. The latter is generally favoured by all patients as this represents the physiological posture during meals.

Results

Using 2-tailed paired sample T-test, comparison across all cases showed a consistently lower median Integrated Relaxation Pressure (IRP) [6.0 mmHg vs to 8.7 mmHg; p <0.01] and lower mean Distal Contractile Integral (DCI) [1463 mmHg/cm/sec vs 1864 mmHg/cm/sec; p =0.014] in the upright posture compared to supine position although the mean Distal Latency (DL) difference was not significant [6.21secs vs 6.27 secs; p =0.491]. During upright and supine position comparison respectively, subgroup analysis on subjects with normal HREM diagnosis showed even lower median IRP [4.9 mmHg vs 7.5 mmHg; p <0.01] and lower mean DCI results [1436 mmHg/cm/sec vs 1695 mmHg/cm/sec; p <0.01] with mean DL in this subgroup showing no significant statistical difference [6.29 secs vs 6.38secs; p=0.545]. The final HREM diagnosis in upright position is concordant with the conventional supine position up to 81.7% and showed an even higher concordance in terms of management similarity up to 98.1%. Only 2 cases (2/104) showed a significant discordance between supine and upright HREM diagnosis [normal HREM vs esophagogastric juntion –outflow obstruction(EGJ-OO) and hypercontractile esophagus vs normal HREM]. Minor diagnostic discordance [normal HREM vs ineffective esophageal motility (IEM)] was noted in 17/104 cases which had no major clinical impact on patients and may be overcome by adopting a lower cut-off for mean DCI for upright group.

Conclusion

In patients who are unable to perform HREM in supine position, adopting the upright position shows a high clinical concordance and may be considered a more physiological approach in the HREM protocol.

References

Riva CG, Siboni S, Ferrari D, Sozzi M, Capuzzo M, Asti E, Ogliari C, Bonavina L. Effect of Body Position on High-resolution Esophageal Manometry Variables and Final Manometric Diagnosis. J Neurogastroenterol Motil. 2020 Jul 30;26(3):335-343. doi: 10.5056/jnm20010. PMID: 32606256; PMCID: PMC7329148.

Introduction

According to guidelines, in order to strictly diagnose esophageal motility disorders, besides achalasia, high resolution manometry (HRM) findings should be documented in both the upright and the supine position. A common finding among patients with Gastro-Esophageal Reflux Disease GERD submitted to manometry is ineffective esophageal motility (IEM). The clinical impact of such a diagnosis in this setting is ambiguous though it may denote future disturbance of peristaltic reserve even if until now only inadequate response to multiple rapid swallows (MRS) has been correlated to post anti-reflux surgery dysphagia.

Aims & Methods

We aimed to evaluate differences in esophageal contractility in different positions in patients with definite GERD.We included consecutive patients with definite GERD according to Acid Exposure Time (>6%) submitted simultaneously to 24 hours pH impedance off PPI study and HRM in both the upright and supine position. Patients with previous esophago-gastric surgeries as also patients diagnosed with motility disorders besides IEM/absent contractility according to Chicago 4 guidelines were excluded.

Results

In total 49 patients (M/F:26 (53.1%)/23 (46.9%), mean age:51±14) were included. The main referral reason was typical reflux symptoms in 37/49 (75.5%) patients while 8/49 (16.3%) reported dysphagia. Mean Distal Contractile Integral (DCI) was significantly reduced in the upright position (1629.2±1175.6 mm²/s/mmHg) vs supine position (2762.4±2710.4 mm²/s/mmHg), p=0.010. The rate of total ineffective swallows in the upright position was significantly increased in the upright position (29.0%) vs the supine (12.3%), p=0.010 as was also the rate of weak contraction (10.3% vs 3.1%, p=0.033 ) and marginally not of absent contractions (17.0% vs 8.3%, p=0.078). The rate of diagnosis of IEM/absent contractility was doubled in the upright position (8/49, 16.3%) vs in the supine position (4/49, 8.2%) (k-value:0.473, p=0.001). Inadequate post MRS contraction was observed in 9/49 (18.4%) and more specifically among 3/4 (75%) patients with IEM/absent contractility diagnosis in the supine position (k:-0.436, p=0.002) vs 4/8 (50%) in the upright position (k:-0.361, p=0.011). Dysphagia was not correlated to diagnosis of IEM/absent contractility neither in the supine (p=0.675) nor the upright position (p=0.586).

Conclusion

Upright position in HRM is correlated to a decreased mean DCI and an increased rate of ineffective esophageal contractions leading to an increased rate of diagnosis of IEM/absent contractility. Such a diagnosis in the upright position is correlated in a lesser extent to inadequate post-MRS swallow and not correlated to symptom of dysphagia. Until new data arise such an overdiagnosis among patients with GERD may be misleading and therefore the procedure in such patient may be better to be undertaken only in the supine position.