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

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

Idiopathic Achalasia is an esophageal motor disorder characterized by total aperistalsis of the esophageal body associated with insufficient relaxation of the lower esophageal sphincter (LES). Endoscopic treatment of achalasia is mainly done by per endoscopic myotomy (POEM) or pneumatic dilatation (PD). However, in case of failure, surgical treatment should be considered.

Aims & Methods

The objective of our work is to evaluate the efficacy of the treatment by (PD) as well as the predictive factors of success and failure.
Our work is a retrospective descriptive and analytical study, which spans a period of 15 years (from 2007 to 2022).This study included 120 patients who received treatment for their disease.
The ECKARDT score allows a clinical evaluation of the patients. It is based on endoscopic clinical data, the results of the manometry and those of the treatment by PD.

Results

We identified 120 patients. The average age was 45.1 years with (17 and 88 years). The sex distribution in our study was 55 men and 65 women with a sex ratio of 1.2 F/H.
Clinical signs found: dysphagia was found in all patients (100%), regurgitation was found in 35% of patients (n=42), weight loss was observed in 29% of patients (n=35), chest pain was found in 3.6% of patients (n=4). An EcKardt score more than 3 was observed in 79.1% of patients (n=95).
Manometry showed an increase in lower esophageal pressure in 5% of patients (n=6), incomplete relaxation of the lower esophageal sphincter in 10% of patients (n=12) and hypertonicity of the lower esophageal sphincter in 17.5% of patients (n=21). Achalasia type I was found in 5.8% of patients and type II in 7.5% of patients
Upper GI endoscopy revealed a sign of a protrusion in 61.7% of patients (n=74), a dilated esophagus with food stasis in 58.3% of patients (n=70), a negotiable stenosis in 25.8% of patients (n=30) and an impassable stenosis in 2.5% of patients (n=3).
Endoscopic treatment by pneumatic dilatation was initiated in 85.8% of patients (n=103) and surgical treatment in 4% of patients (n=5).
Of the 116 patients who received PD, 88.7% (n=103) went into remission and 8.3% (n=10) relapsed.
After a uni and multivariate analysis, the factors that predicted the success of pneumatic dilatation were: age under 40 years with a p=0.001 value, the aperectness of the esophageal body with a p=0.01 value.

Conclusion

In our study, the great majority of the patients benefited from a treatment by pneumatic dilatation with a success rate of 88.7%. We can therefore conclude that pneumatic dilatation remains the treatment of choice for the management of achalasia. The predictive factors of success are therefore the low age of the patients and the presence of esophageal aperistalsis.

Introduction

Oesophageal achalasia is a motility disorder characterized by the lack of relaxation of the lower oesophageal sphincter and absence of normal oesophageal motility. Among endoscopic techniques to treat achalasia, highlight peroral oesophageal endoscopic miotomy (POEM) and endoscopic balloon dilatation (ED). Some studies demonstrate that ED could achieve similar results to traditional surgical technique (Heller miotomy). However, studies comparing POEM and repeated ED protocols are lacking.

Aims & Methods

Objectives: To compare manometric and clinical data from a group of patients with achalasia treated with a 2-session endoscopic dilatation protocol (EDx2) vs POEM.
Material and Methods: We performed a retrospective review of oesophageal high-resolution manometry (HRM) and clinical records of patients with achalasia treated with EDx2 (30 and 35 mm balloon separated by 2 weeks) or POEM. Only patients with pre and post-treatment HRM were included. Data regarding epidemiological (age, sex), clinical (Eckardt score, complications) and HRM (integrated relaxation pressure, achalasia subtype, rapid drink challenge) were recorded. Technical success was defined as post-treatment IRP < 15 mmHg, clinical success was defined as post-treatment Eckardt score < 3 points, and global success when both conditions were present

Results

Sixty-one patients were included, 32 treated with EDx2 and 29 with POEM. Of those, 67% were type II, 20% type III and 13% type I achalasia. Main baseline characteristics were similar between groups except for a higher baseline Eckardt score in POEM. Both techniques show similar results regarding technical success (69% DB vs 86% POEM, p=ns), clinical success (93 DB vs 93% POEM, p=ns) and overall success (61% DB vs 79% POEM, p=ns). However, when analysing the success according to subgroups of achalasia, we found a trend to greater overall success with POEM in type III achalasia (EDx2 33% vs POEM 100%, p=0.06). No differences were found between both techniques in overall success for type II (68% DB vs 79% POEM, p=ns) and type I (67% DB vs 60% POEM, p=ns) achalasia.

Conclusion

A 2-session endoscopic dilatation protocol achieved therapeutic success similar to POEM in type I and type II achalasia. In type III achalasia, POEM seems superior to endoscopic dilatation.