|
1
|
Miller JD, Mitchell ZL, Ellington AL, Peoples FA, Clayton SB. Functional Lumen Imaging Probe Measurement Post-Pneumatic Dilation in Clinically Relevant Esophagogastric Junction Outlet Obstruction. Neurogastroenterol Motil 2025:e70053. [PMID: 40273370 DOI: 10.1111/nmo.70053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2025] [Revised: 03/10/2025] [Accepted: 03/31/2025] [Indexed: 04/26/2025]
Abstract
BACKGROUND Pneumatic dilation (PD) is an effective treatment for disorders of reduced esophageal opening. Functional lumen impedance planimetry (FLIP) can effectively measure lower esophageal sphincter (LES) physiology compared to esophageal standards. The aim of this retrospective cohort analysis was to evaluate if FLIP measurements and esophageal opening classifications changed consistently with symptom improvement post-PD. Also, the aim was to determine if post-PD FLIP measurement correlated with the need for repeat dilation. METHODS Patients with clinically significant esophagogastric junction outlet obstruction (EGJOO) with reduced esophageal opening (REO) or borderline REO (BrEO) based on FLIP, timed barium esophagram (TBE), and manometry who underwent PD were included. Post-PD FLIP measurements were taken immediately after PD during the same endoscopy encounter. RESULTS After PD, average distensibility index (DI) increased from 1.5 mm2/mmHg to 4.7 mm2/mmHg (p < 0.001) and diameter changed from 8.9 mm to 15.9 mm (p < 0.001). Average post-dilation Eckardt score was 1.2, decreasing from an average pre-dilation score of 6.25. Of those requiring repeat dilations, average post-dilation DI was 4.5 mm2/mmHg and diameter 16.4 mm, not statistically different from those that did not undergo repeat procedure (p = 0.79, 0.67, respectively). Post-dilation esophageal openings were all NEO or BnEO. Average Eckardt score at 6-8 week follow-up was not significantly different from those who did not require repeat dilation (1.4, p = 0.112). CONCLUSIONS PD appears to be associated with improved esophageal opening and a significant change in both DI and diameter, consistent with an improved Eckardt score. Post-dilation DI, diameter, esophageal opening pattern, and Eckardt score did not reveal a trend indicating the need for repeat dilation.
Collapse
Affiliation(s)
- James D Miller
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Zachary L Mitchell
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Abigail L Ellington
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Felicia A Peoples
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Steven B Clayton
- Section on Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
|
2
|
Duy L, Clayton S, Morimoto N, Wang S, DiSantis D. Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes. Abdom Radiol (NY) 2025; 50:1488-1497. [PMID: 39317828 PMCID: PMC11947050 DOI: 10.1007/s00261-024-04554-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 08/23/2024] [Accepted: 08/27/2024] [Indexed: 09/26/2024]
Abstract
Achalasia is a rare esophageal motility disorder characterized by lack of primary peristalsis and a poorly relaxing lower esophageal sphincter. This disease process can be examined several ways and these evaluations can offer complementary information. There are three manometric subtypes of achalasia, with differing appearances on esophagram. Differentiating them is clinically important, because treatment for the subtypes varies. Timed barium esophagram (TBE) is a simple test to quantitatively evaluate esophageal emptying. TBE can be used to diagnose achalasia and assess treatment response. Considerable variation in the TBE protocol exist in the literature. We propose a standardized approach for TBE to allow for comparison across institutions.
Collapse
Affiliation(s)
- Lindsay Duy
- Department of Radiology, Wake Forest University School of Medicine, Winston Salem, USA.
| | - Steven Clayton
- Department of Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, USA
| | - Nayeli Morimoto
- Department of Radiology, Stanford University School of Medicine, Stanford, USA
| | - Shery Wang
- Department of Radiology, Mayo Clinic, Rochester, USA
| | | |
Collapse
|
|
3
|
Fass OZ, Pandolfino JE, Schauer JM, Ganesh N, Farina DA, Lat A, Goudie E, Kelahan LC, Carlson DA. Diagnostic Accuracy of Timed Barium Esophagram for Achalasia. Gastroenterology 2025:S0016-5085(25)00421-4. [PMID: 40020937 DOI: 10.1053/j.gastro.2025.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Revised: 01/13/2025] [Accepted: 02/03/2025] [Indexed: 03/03/2025]
Abstract
BACKGROUND & AIMS Timed barium esophagram (TBE) is commonly used to evaluate esophageal motor disorders, though its accuracy is limited. The lack of standardized criteria for TBE interpretation, coupled with reliance on single measurements and outdated reference standards, limits its effectiveness. This study aimed to reexamine the accuracy of TBE interpretation using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) approach and updated reference standards. METHODS Adult patients with esophageal dysphagia were prospectively enrolled from 2019 to 2022 and underwent motility testing with esophageal manometry, functional lumen imaging probe (FLIP) panometry, and TBE. TBE accuracy for predicting achalasia/FLIP+ esophagogastric junction (EGJ) outflow obstruction, as defined by Chicago Classification 4.0 and FLIP, was assessed using 2 approaches: barium column height >2 cm at 5 minutes/impacted tablet and a classification tree model. RESULTS The study included 290 participants: 121 (42%) with EGJ outflow disorders, 151 (52%) without, and 18 (6%) with inconclusive results. The optimal classification tree had 3 levels: maximum esophageal body width at the top, maximum EGJ diameter and barium height at the second level, and tablet passage at the bottom. The TBE column height and tablet approach had a sensitivity of 77.8%, specificity 86.0%, and accuracy 82.2%, whereas the classification tree model achieved a sensitivity of 84.2%, specificity 92.1%, and accuracy of 88.3%. CONCLUSIONS TBE can accurately identify achalasia/FLIP+ EGJ outflow obstruction when using multiple metrics in a classification tree model. This provides a simple, standardized approach to TBE interpretation that is superior to traditional single-metric methods.
Collapse
Affiliation(s)
- Ofer Z Fass
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John E Pandolfino
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jacob M Schauer
- Division of Biostatistics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Nisha Ganesh
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Domenico A Farina
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ayesha Lat
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Eric Goudie
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Division of Thoracic Surgery, Department of Surgery, Université de Montréal, Montreal, Quebec, Canada
| | - Linda C Kelahan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Dustin A Carlson
- Kenneth C. Griffin Esophageal Center of Northwestern Medicine, Department of Medicine, Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
|
4
|
Blonski W, Jacobs J, Feldman J, Richter JE. The history and use of the timed barium esophagram in achalasia, esophagogastric junction outflow obstruction, and esophageal strictures. Neurogastroenterol Motil 2025; 37:e14928. [PMID: 39345000 DOI: 10.1111/nmo.14928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/06/2024] [Accepted: 09/15/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Dysphagia is one of the most common complaints that gastroenterologists encounter in the outpatient setting. To evaluate this common complaint, patients are often sent for a barium esophagram, a test that is widely available, inexpensive, and easy to perform. This simple test provides a reliable method to evaluate esophageal anatomy and structural abnormalities. PURPOSE This narrative reviews the history of the development and validation of the timed-barium esophagram (TBE), along with its strengths and limitations, and discusses its use in the pre- and posttreatment assessment of patients with achalasia, esophagogastric junction outflow obstruction (EGJOO), and esophageal strictures. Providing excellent anatomic detail of the esophagus and an accurate assessment of esophageal emptying, over time, the TBE has become part of the standard workup in our Swallowing Center for patients with dysphagia.
Collapse
Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley Veterans' Hospital, Tampa, Florida, USA
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - John Jacobs
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - John Feldman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Joy McCann Culverhouse Center for Esophageal Diseases, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| |
Collapse
|
|
5
|
Mari A, Khoury T, Sweis R. Achalasia: beyond the basics. Frontline Gastroenterol 2025; 16:59-71. [DOI: 10.1136/flgastro-2024-102822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2025] Open
Abstract
Achalasia is a rare oesophageal disease characterised by an unrelaxing lower oesophageal sphincter and abnormal peristalsis of the oesophageal body. Achalasia symptoms include dysphagia to solid and liquid, chest pain, regurgitation and weight loss. Achalasia diagnosis might be delayed for many years when atypical symptoms dominate. Significant progress has been made over the last two decades regarding our understanding of pathophysiology, methods of evaluation and management. The development of high-resolution manometry in particular has improved the diagnosis of achalasia, as well as other major motility disorders. Subtyping achalasia into manometric patterns has pathophysiological and therapeutic implications. Furthermore, complementary tests such as timed barium swallow and the functional lumen imaging probe (EndoFLIP; Crospon Medical Devices, Galway, Ireland) have significantly added to achalasia diagnosis algorithm and management decision-making. Progression in management has helped optimise established therapy (pneumatic dilatation and Heller myotomy) and introduced new endoscopic treatments (peroral endoscopic myotomy) and surgical techniques (surgical robotic Heller myotomy). This review will aim to shed light on the most recent advances in achalasia diagnosis, classification and management.
Collapse
|
|
6
|
Suwatthanarak T, Phalanusitthepa C, Thongchuam C, Akaraviputh T, Chinswangwatanakul V, Tawantanakorn T, Leelakusolvong S, Maneerattanaporn M, Apisarnthanarak P, Wasinrat J. Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand. Clin Endosc 2024; 57:610-619. [PMID: 38872406 PMCID: PMC11474463 DOI: 10.5946/ce.2023.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND/AIMS Achalasia is a rare esophageal motility disease, for which peroral endoscopic myotomy (POEM) has emerged as a promising treatment option; however, recurrence remains a challenge. Timed barium esophagography (TBE) is a useful diagnostic tool and potential outcome predictor of achalasia. This study aimed to determine predictive tools for recurrence after POEM. METHODS This retrospective study enrolled achalasia patients who underwent POEM between January 2015 and December 2021. Patients were categorized into two groups using the 1-month post-POEM Eckardt scores and TBE: the discordant group (Eckardt score improved >50%, TBE decreased <50%) and the concordant group (both Eckardt score and TBE improved >50%). Recurrence was defined as a reincrease in the Eckardt score to more than three during follow-up. RESULTS Complete medical records were available in 30 patients who underwent POEM. Seventeen patients (56.7%) were classified into the discordant group, while 13 patients (43.3%) were in the concordant group. The overall recurrence rate was 11.9% at 1-year, increasing to 23.8% during the extended follow-up. The discordant group had a 6.87 fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). CONCLUSIONS These results strongly suggest that combining the Eckardt score with TBE can effectively predict recurrent achalasia after POEM. Patients in the discordant group had an elevated risk.
Collapse
Affiliation(s)
- Tharathorn Suwatthanarak
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Chainarong Phalanusitthepa
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatbadin Thongchuam
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thawatchai Akaraviputh
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vitoon Chinswangwatanakul
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thikhamporn Tawantanakorn
- Minimally Invasive Surgery Unit, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Leelakusolvong
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monthira Maneerattanaporn
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piyaporn Apisarnthanarak
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jitladda Wasinrat
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
|
7
|
Lee TH. Never judge a book by its cover: the role of timed barium esophagography in patients with complete symptom relief after peroral endoscopic myotomy. Clin Endosc 2024; 57:604-605. [PMID: 39354832 PMCID: PMC11474466 DOI: 10.5946/ce.2024.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/09/2024] [Accepted: 06/10/2024] [Indexed: 10/03/2024] Open
Affiliation(s)
- Tae Hee Lee
- Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| |
Collapse
|
|
8
|
Hultcrantz J, Klevebro F, Lindblad M, Brismar TB, Coy DL, Low DE, Andersson M. Improved radiologic diagnosis of delayed gastric conduit emptying (DGCE) after esophagectomy using a functional upper gastrointestinal contrast study. Acta Radiol 2024; 65:329-333. [PMID: 38111253 DOI: 10.1177/02841851231217990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND With increasing incidence of esophageal cancer, a growing number of patients are at risk of developing delayed gastric conduit emptying (DGCE) in the early postoperative phase after esophagectomy. This condition is of great postoperative concern due to its association with adverse outcomes. PURPOSE To give a narrative review of the literature concerning radiological diagnosis of DGCE after esophagectomy and a proposal for an improved, functional protocol with objective measurements. MATERIAL AND METHODS The protocol was designed at Virginia Mason Medical Center in Seattle and is based on the Timed Barium Esophagogram (TBE) concept, which has been adapted to assess the passage of contrast from the gastric conduit into the duodenum. RESULTS The literature review showed a general lack of standardization and scientific evidence behind the use of radiology to assess DGCE. We found that our proposed standardized upper gastrointestinal (UGI) contrast study considers both the time aspect in DGCE and provides morphologic information of the gastric conduit. This radiological protocol was tested on 112 patients in a trial performed at two high-volume centers for esophageal surgery and included an UGI contrast study 2-3 days postoperatively. The study demonstrated that this UGI contrast study can be included in the standardized clinical pathway after esophagectomy. CONCLUSION This new, proposed UGI contrast study has the potential to diagnose early postoperative DGCE in a standardized manner and to improve overall patient outcomes after esophagectomy.
Collapse
Affiliation(s)
- Jens Hultcrantz
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - David L Coy
- Department of Radiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Mats Andersson
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
|
9
|
Reddy CA, Ellison A, Cipher DJ, Mendoza R, Souza RF, Spechler SJ, Konda VJA, Nguyen AD. Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction. Neurogastroenterol Motil 2024; 36:e14729. [PMID: 38129627 DOI: 10.1111/nmo.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/19/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes. METHODS We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction. KEY RESULTS A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764). CONCLUSIONS & INFERENCE High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.
Collapse
Affiliation(s)
- Chanakyaram A Reddy
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Ashton Ellison
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Daisha J Cipher
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Roseann Mendoza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Rhonda F Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Stuart J Spechler
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Vani J A Konda
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| | - Anh D Nguyen
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas, USA
| |
Collapse
|
|
10
|
Chuah KH, Ramasami N, Mahendran HA, Shanmuganathan G, Koleth GG, Voon K, Gew LT, Jahit MS, Lau PC, Muthukaruppan R, Said RHM, Mahadeva S, Ho SH, Lim SY, Tee SC, Siow SL, Ooi WK, Lee YY. Malaysian joint societies' consensus recommendations on diagnosis and management of disorders of esophagogastric junction outflow. J Gastroenterol Hepatol 2024; 39:431-445. [PMID: 38087846 DOI: 10.1111/jgh.16403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 09/13/2023] [Accepted: 10/18/2023] [Indexed: 03/05/2024]
Abstract
Disorders of esophagogastric junction (EGJ) outflow, including achalasia and EGJ outflow obstruction, are motility disorders characterized by inadequate relaxation of lower esophageal sphincter with or without impaired esophageal peristalsis. Current guidelines are technical and less practical in the Asia-Pacific region, and there are still massive challenges in timely diagnosis and managing these disorders effectively. Therefore, a Malaysian joint societies' task force has developed a consensus on disorders of EGJ outflow based on the latest evidence, while taking into consideration the practical relevance of local and regional context and resources. Twenty-one statements were established after a series of meetings and extensive review of literatures. The Delphi method was used in the consensus voting process. This consensus focuses on the definition, diagnostic investigations, the aims of treatment outcome, non-surgical or surgical treatment options, management of treatment failure or relapse, and the management of complications. This consensus advocates the use of high-resolution esophageal manometry for diagnosis of disorders of EGJ outflow. Myotomy, via either endoscopy or laparoscopy, is the preferred treatment option, while pneumatic dilatation can serve as a secondary option. Evaluation and management of complications including post-procedural reflux and cancer surveillance are recommended.
Collapse
Affiliation(s)
- Kee Huat Chuah
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Naveen Ramasami
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultanah Bahiyah Hospital, Alor Setar, Kedah, Malaysia
| | | | | | - Glenn George Koleth
- Gastroenterology and Hepatology Unit, Department of Medicine, Sultan Ismail Hospital, Johor Bahru, Johor, Malaysia
| | - Kelvin Voon
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Lai Teck Gew
- Gastroenterology and Hepatology Unit, Department of Medicine, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | | | - Peng Choong Lau
- Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
- Department of Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Raman Muthukaruppan
- Gastroenterology and Hepatology Unit, Department of Medicine, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Rosaida Hj Md Said
- Gastroenterology and Hepatology Unit, Department of Medicine, Serdang Hospital, Serdang, Selangor, Malaysia
| | - Sanjiv Mahadeva
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shiaw-Hooi Ho
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shyang Yee Lim
- Department of General Surgery, Penang General Hospital, George Town, Penang, Malaysia
| | - Sze Chee Tee
- Department of Surgery, National Cancer Institute, Putrajaya, Malaysia
| | - Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Wei Keat Ooi
- Department of Surgery, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- GI Function and Motility Unit, Universiti Sains Malaysia Hospital, Kota Bharu, Kelantan, Malaysia
| |
Collapse
|
|
11
|
Kim N. Esophageal Diseases. SEX/GENDER-SPECIFIC MEDICINE IN CLINICAL AREAS 2024:55-93. [DOI: 10.1007/978-981-97-0130-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
|
|
12
|
Wakim El-Khoury J, Pandolfino JE, Kahrilas PJ, Godo B, Farina DA, Kou W, Carlson DA. Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry. Neurogastroenterol Motil 2023; 35:e14663. [PMID: 37691556 DOI: 10.1111/nmo.14663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/29/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension. METHODS Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0). KEY RESULTS Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM. CONCLUSIONS AND INFERENCES This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.
Collapse
Affiliation(s)
- Jeanine Wakim El-Khoury
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
- Division of Gastroenterology and Hepatology, Department of Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - John E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter J Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bidemi Godo
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Domenico A Farina
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Wenjun Kou
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
|
13
|
Sanagapalli S, Plumb A, Lord RV, Sweis R. How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia. Neurogastroenterol Motil 2023; 35:e14605. [PMID: 37103465 DOI: 10.1111/nmo.14605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities. PURPOSE The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.
Collapse
Affiliation(s)
- Santosh Sanagapalli
- Department of Gastroenterology and Hepatology, St. Vincent's Hospital Sydney, Darlinghurst, Australia
- School of Clinical Medicine, St. Vincent's Healthcare Campus, University of New South Wales, Sydney, Australia
| | - Andrew Plumb
- Centre for Medical Imaging, University College London Hospital, London, UK
| | - Reginald V Lord
- Department of Surgery, University of Notre Dame School of Medicine, Sydney, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
| |
Collapse
|
|
14
|
Koop AH, Kahrilas PJ, Schauer J, Pandolfino JE, Carlson DA. The impact of primary peristalsis, contractile reserve, and secondary peristalsis on esophageal clearance measured by timed barium esophagogram. Neurogastroenterol Motil 2023; 35:e14638. [PMID: 37417394 PMCID: PMC11558462 DOI: 10.1111/nmo.14638] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Primary and secondary peristalsis facilitate esophageal bolus transport; however, their relative impact for bolus clearance remains unclear. We aimed to compare primary peristalsis and contractile reserve on high-resolution manometry (HRM) and secondary peristalsis on functional lumen imaging probe (FLIP) Panometry with emptying on timed barium esophagogram (TBE) and incorporate findings into a comprehensive model of esophageal function. METHODS Adult patients who completed HRM with multiple rapid swallows (MRS), FLIP, and TBE for esophageal motility evaluation and without abnormal esophagogastric junction outflow/opening or spasm were included. An abnormal TBE was defined as a 1-min column height >5 cm. Primary peristalsis and contractile reserve after MRS were combined into an HRM-MRS model. Secondary peristalsis was combined with primary peristalsis assessment to describe a complementary neuromyogenic model. KEY RESULTS Of 89 included patients, differences in rates of abnormal TBEs were observed with primary peristalsis classification (normal: 14.3%; ineffective esophageal motility: 20.0%; absent peristalsis: 54.5%; p = 0.009), contractile reserve (present: 12.5%; absent: 29.3%; p = 0.05), and secondary peristalsis (normal: 9.7%; borderline: 17.6%; impaired/disordered: 28.6%; absent contractile response: 50%; p = 0.039). Logistic regression analysis (akaike information criteria, area under the receiver operating curve) demonstrated that the neuromyogenic model (80.8, 0.83) had a stronger relationship predicting abnormal TBE compared to primary peristalsis (81.5, 0.82), contractile reserve (86.8, 0.75), or secondary peristalsis (89.0, 0.78). CONCLUSIONS AND INFERENCES Primary peristalsis, contractile reserve, and secondary peristalsis were associated with abnormal esophageal retention as measured by TBE. Added benefit was observed when applying comprehensive models to incorporate primary and secondary peristalsis supporting their complementary application.
Collapse
Affiliation(s)
- Andree H. Koop
- Division of Gastroenterology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter J. Kahrilas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jacob Schauer
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dustin A. Carlson
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
|
15
|
Keller J. [Esophageal Motility Disorders - What's New?]. Dtsch Med Wochenschr 2023; 148:1187-1200. [PMID: 37657457 DOI: 10.1055/a-1664-7458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Esophageal motor disorders are an important cause of dysphagia but can also be associated with retrosternal pain and heartburn as well as regurgitation. In extreme cases, patients are not able to eat appropriately and lose weight. Repetitive aspiration can occur and may cause pulmonological complications. Achalasia represents the most important and best-defined esophageal motor disorder and is characterized by insufficient relaxation of the lower esophageal sphincter in combination with typical disturbances of esophageal peristalsis. Additional defined motor disorders are distal esophageal spasm, hypercontractile esophagus, absent contractility and ineffective peristalsis. Patients with appropriate symptoms should primarily undergo esophagogastroduodenoscopy for exclusion of e.g., tumors and esophagitis. Esophageal high-resolution manometry is the reference method for diagnosis and characterization of motor disorders in non-obstructive dysphagia. An esophagogram with barium swallow may deliver complementary information or may be used if manometry is not available. Balloon dilatation and Heller myotomy are long established and more or less equally effective therapeutic options for patients with achalasia. Peroral endoscopic myotomy (POEM) enhances the therapeutic armamentarium for achalasia and hypertensive/spastic motor disorders since 2010. For hypotensive motor disorders, which may occur as a complication of e.g., rheumatological diseases or idiopathically, therapeutic options are still limited.
Collapse
|
|
16
|
Srivastava A, Poddar U, Mathias A, Mandelia A, Sarma MS, Lal R, Yachha SK. Achalasia cardia sub-types in children: Does it affect the response to therapy? Indian J Gastroenterol 2023; 42:534-541. [PMID: 37300794 DOI: 10.1007/s12664-023-01344-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/26/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Achalasia sub-types affect treatment response in adults, but there is no similar data in children. We studied the differences in clinico-laboratory features and response to therapy between achalasia sub-types in children. METHODS Forty-eight children (boys:girls-25:23, 14 [0.9-18] years) with achalasia (clinical, barium, high-resolution manometry [HRM], gastroscopy) were evaluated. The sub-type was determined by Chicago classification at HRM. Pneumatic dilatation (PD) or surgery was the primary therapy. Success was defined as Eckhardt score of ≤ 3. RESULTS Dysphagia (95.8%) and regurgitation (93.8%) were the most common symptoms. Forty of 48 cases had an adequate HRM study: Type I (n-19), II (n-19) and III (n-2). Types I and II had similar clinical profile. Type II had higher basal lower esophageal sphincter (LES) pressure (30.5 [16.5-46] vs. 22.5 [13-43] mmHg; p = 0.007) and less dilated esophagus on timed barium esophagogram (TBE, 25 [13-57] vs. 34.5 [20-81] mm; p = 0.006) than type I. Both types had similar success (86.6% [13/15] vs. 92.8% [13/14]; p = 1) after first PD and need of post-PD myotomy (5/17 vs. 1/16; p = 0.1) in follow-up. Twenty-three cases had TBE before and after PD; 15 (65.2%) had good clearance. These subjects required myotomy (1/15 vs. 4/8; p = 0.03) and repeat PD (5/15 vs. 4/8; p = 0.08) less often than those with poor clearance on TBE. CONCLUSION Types I and II achalasia have similar frequency and clinical profile. Type II has higher LES pressure and less dilated esophagus than Type I. Both respond equally well to initial PD. Type I required post-PD myotomy more often, though not significantly. TBE is useful for assessing therapeutic response.
Collapse
Affiliation(s)
- Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Ankur Mandelia
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Richa Lal
- Pediatric Surgical Superspecialty, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| |
Collapse
|
|
17
|
Blonski W, Slone S, Richter JE. Update on the Diagnosis and Treatment of Achalasia. Dysphagia 2023; 38:596-608. [PMID: 35585208 DOI: 10.1007/s00455-022-10435-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 03/04/2022] [Indexed: 12/23/2022]
Abstract
Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.
Collapse
Affiliation(s)
- Wojciech Blonski
- Division of Gastroenterology, James A. Haley VA Hospital, Tampa, FL, USA
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Samuel Slone
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA
| | - Joel E Richter
- Division of Gastroenterology and Nutrition, Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, MDC 72, Tampa, FL, 33612, USA.
- Joy McCann Culverhouse Center for Esophageal Diseases, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| |
Collapse
|
|
18
|
Blonski W, Kumar A, Jacobs J, Feldman J, Richter JE. Impact of opioids on treatment response among idiopathic esophagogastric junction outflow obstruction patients: A retrospective cohort study. Indian J Gastroenterol 2023; 42:136-142. [PMID: 36781814 DOI: 10.1007/s12664-022-01311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 11/07/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Esophageal dysmotility has been attributed to opioid use. The goal was to assess the differences in pre- and post-treatment timed-barium esophagram (TBE) barium heights at 1 and 5 minutes and symptomatic response to treatment in esophagogastric junction outflow obstruction (EGJOO) patients according to opioid use status. METHODS We performed a retrospective cohort study. Consecutive patients with EGJOO were eligible for inclusion. Data were collected on demographics, pre and post-treatment 1 and 5 minutes TBE barium heights and symptom outcomes. Groups were compared according to opioid use. RESULTS Thirty-one EGJOO patients met the inclusion criteria. All patients were treated with pneumatic dilation. Of the 31 patients, 11 (35%) had opioid exposure and 20 (65%) did not. The median follow-up post-treatment was two months (range 1-47 months). There was no statistically significant difference in post-treatment outcomes for opioid exposed vs. unexposed groups. The median per cent decrease in the TBE barium height at 1 minute was 100% for the opioid exposed vs. 71% for the unexposed group (p = 0.92). The median per cent decrease in the TBE barium height at 5 minutes was zero % for the opioid exposed and unexposed groups (p = 0.67). The incidence of symptomatic improvement was 82% (9/11) for the opioid exposed group vs 95% (19/20) for the unexposed group (p = 0.28). CONCLUSIONS Patients with EGJOO seem to respond to treatment similarly regardless of being on opioids.
Collapse
Affiliation(s)
- Wojciech Blonski
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA
- Department of Gastroenterology, James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - John Jacobs
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA
| | - John Feldman
- Department of Radiology, University of South Florida Health Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Health Morsani College of Medicine, 12901 Bruce B. Downs Blvd. MDC 72, Tampa, FL, 33612, USA.
| |
Collapse
|
|
19
|
Penagini R, de Bortoli N, Savarino E, Arsiè E, Tolone S, Greenan G, Visaggi P, Maniero D, Mauro A, Consonni D, Gyawali CP. Rapid Drink Challenge During High-resolution Manometry for Evaluation of Esophageal Emptying in Treated Achalasia. Clin Gastroenterol Hepatol 2023; 21:55-63. [PMID: 35240328 DOI: 10.1016/j.cgh.2022.02.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Incomplete esophageal emptying is a key variable predicting symptom relapse after achalasia treatment. Although optimally evaluated using the timed barium esophagogram (TBE), incomplete esophageal emptying can also be identified on rapid drink challenge (RDC) performed during high-resolution manometry. METHODS We evaluated if RDC differentiates complete from incomplete esophageal emptying in treated patients with achalasia, against a TBE gold standard. Unselected treated patients with achalasia with both TBE (200 mL of low-density barium suspension) and RDC (200 mL of water in sitting position) were enrolled in 5 tertiary referral centers. TBE barium column height at 1, 2, and 5 minutes were compared with RDC variables: pressurizations >20 mmHg, maximal RDC pressurization, proportion of RDC time occupied by pressurizations, trans-esophagogastric junction gradient, and integrated relaxation pressure. RESULTS Of 175 patients recruited (mean age, 59 years; 47% female), 138 (79%) were in clinical remission. Complete TBE emptying occurred in 45.1% at 1 minute, 64.0% at 2 minutes, and 73.1% at 5 minutes. RDC integrated relaxation pressure correlated strongly with TBE column height, and a 10-mmHg threshold discriminated complete from incomplete emptying at all 3 TBE time points with area under receiver operating characteristic curves of 0.85, 0.87, and 0.85, respectively. This threshold had high negative predictive values for complete emptying (88% at 2 minutes, 94% at 5 minutes), and modest positive predictive values for incomplete emptying (77% at 2 minutes, 62% at 5 minutes). CONCLUSIONS RDC during high-resolution manometry is an effective surrogate for TBE in assessing esophageal emptying in treated patients with achalasia.
Collapse
Affiliation(s)
- Roberto Penagini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Nicola de Bortoli
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Savarino
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Elena Arsiè
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Salvatore Tolone
- Surgery Unit, Department of Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Garrett Greenan
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| | - Pierfrancesco Visaggi
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Daria Maniero
- Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Aurelio Mauro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; San Matteo Hospital Foundation, University of Pavia, Endoscopy Unit, Pavia, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
|
20
|
Evensen H, Hjermstad MJ, Cvancarova M, Kristensen V, Larssen L, Skattum J, Hauge T, Sandstad O, Medhus AW. Quality of life in patients with achalasia: Associations with Eckardt score and objective treatment outcomes after peroral endoscopic myotomy. Endosc Int Open 2022; 10:E1570-E1576. [PMID: 36531682 PMCID: PMC9754863 DOI: 10.1055/a-1968-7682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/25/2022] [Indexed: 10/31/2022] Open
Abstract
Background and study aims Knowledge on self-reported quality of life (QoL) in achalasia and QoL improvements after peroral endoscopic myotomy (POEM) is limited. Furthermore, the clinical role of QoL in achalasia follow-up has not been evaluated. The present study aimed to examine QoL in achalasia patients before and after POEM and assess associations between QoL, Eckardt score (ES) and objective results. Patients and methods This was a single-center prospective study of treatment-naïve achalasia patients with 12-month follow-up after POEM including manometry, upper endoscopy, 24-hour pH registration, and timed barium esophagogram. QoL data were registered using European Organisation for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal module (QLQ-OES18). Comparison with a reference population was performed to assess impact of achalasia on QoL and effect of therapy. Mixed models for repeated measures were applied. Results Fifty patients (26 females) with a median age of 47 years (18-76) were included. Before treatment, all QoL domains were significantly impaired compared with an age- and gender-adjusted reference population ( P < 0.05). No significant QoL-differences were found after POEM, except for fatigue and nausea/vomiting. Clinically relevant QoL improvement was observed in ≥ 50 % of the patients in all QoL domains, except for physical and role functioning. QoL was significantly associated with ES ( P < 0.05) but not with objective results. Conclusions Achalasia is associated with severe QoL impairment. Following POEM, a significant and clinically relevant QoL improvement is observed. QoL is associated with ES, but not with objective results after POEM.
Collapse
Affiliation(s)
- Helge Evensen
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Medicine, University of Oslo, Norway
| | - Marianne Jensen Hjermstad
- Regional Advisory Unit for Palliative Care, Dept. of Oncology, Oslo University Hospital, Norway,European Palliative Care Research Centre (PRC), Dept. of Oncology, Oslo University Hospital, Norway,Institute of Clinical Medicine, University of Oslo, Norway
| | - Milada Cvancarova
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Health Sciences, Oslo Metropolitan University, Norway
| | - Vendel Kristensen
- Department of Gastroenterology, Oslo University Hospital, Norway,Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Norway
| | - Jorunn Skattum
- Department of Abdominal Surgery, Innlandet Hospital Trust, Hamar, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Norway,Faculty of Medicine, University of Oslo, Norway
| | - Olav Sandstad
- Department of Gastroenterology, Oslo University Hospital, Norway
| | - Asle W. Medhus
- Department of Gastroenterology, Oslo University Hospital, Norway
| |
Collapse
|
|
21
|
Abstract
A precise diagnosis is key to the successful treatment of achalasia. Barium swallow, upper endoscopy and high-resolution manometry provide the necessary information about a patient's anatomy, absence of other diseases, and type of achalasia (I, II, III). High-resolution manometry also has prognostic value, the best results of treatment being obtained in type II achalasia according to the Chicago classification. Abdominal CT scanning and endoscopic ultrasound might be warranted if an underlying malignancy is suspected.
Collapse
Affiliation(s)
- Federica Riccio
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Azienda Ospedale Università di Padova, University of Padova, Padua, Italy.
| |
Collapse
|
|
22
|
Ichkhanian Y, Brewer Gutierrez O, Roman S, Yoo IK, Canakis A, Pawa R, Koch K, Su B, Ujiki M, Alsheik E, Zuchelli T, Piraka C, Ghandour B, Zhang L, Sloan JA, Khashab MA. Role of functional luminal imaging probe in the management of postmyotomy clinical failure. Gastrointest Endosc 2022; 96:9-17.e3. [PMID: 35149045 DOI: 10.1016/j.gie.2022.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/01/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment. METHODS This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy. RESULTS One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n = 53, 43%) or POEM (n = 70, 57%) for the management of achalasia (n = 98) or other EDDs (n = 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15 mm Hg on HRM and distensibility index (DI) <2.8 mm2/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P = .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P = .03). CONCLUSIONS The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.
Collapse
Affiliation(s)
- Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA; Department of Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Sabine Roman
- Department of Gastroenterology, Edouard Herriot Hospital, Hospices Civils de Lyon and Lyon University, Lyon, France
| | - In Kyung Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rishi Pawa
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Kenneth Koch
- Division of Gastroenterology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bailey Su
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University Health System, Evanston, Illinois, USA
| | - Eva Alsheik
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Tobias Zuchelli
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Cyrus Piraka
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Linda Zhang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| |
Collapse
|
|
23
|
Shieh TY, Chen CC, Chou CK, Hu TY, Wu JF, Chen MJ, Wang HP, Wu MS, Tseng PH. Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan. J Formos Med Assoc 2022; 121:1123-1132. [PMID: 34753630 DOI: 10.1016/j.jfma.2021.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/13/2021] [Accepted: 10/20/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/OBJECTIVE Peroral endoscopic myotomy (POEM), a novel minimally invasive treatment for esophageal achalasia, is becoming more popular globally because of its efficacy and safety. We aimed to clarify the technical concerns, efficacy, and safety of POEM for treating esophageal achalasia in Taiwan. METHODS We conducted a retrospective study on consecutive patients with achalasia who underwent POEM between October 2016 and May 2021 at three medical centers in Taiwan. All patients underwent a comprehensive work-up before POEM, including symptom questionnaires, esophagogastroduodenoscopy, timed barium esophagogram (TBE), and high-resolution impedance manometry (HRIM), and were re-evaluated three months after POEM. We compared procedure variables, adverse events, and clinical responses, including Eckardt score ≤3 and TBE and HRIM findings. RESULTS We analyzed 92 patients in total (54 men; mean age 49.5 years [range: 20-87]; type I/II/III/unclassified: 24/51/1/16). The mean POEM procedure duration was 89.5 ± 38.2 min, though it was significantly longer in patients with prior treatment or sigmoid-type achalasia. In total, 91 patients (98.9%) showed immediate technical success, and the overall clinical success rate at three months after POEM was 95.7%. Nearly 60% of patients experienced adverse events during POEM, but most of these were mild and none required further endoscopic or surgical intervention. During a follow-up period of up to five years (median 25 months), only four patients (4.3%) showed symptomatic recurrence, but none required further treatment. CONCLUSION POEM is a very effective and safe treatment for Taiwanese patients with achalasia, irrespective of their achalasia subtype or prior treatment failure.
Collapse
Affiliation(s)
- Tze-Yu Shieh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chien-Chuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chu-Kuang Chou
- Division of Gastroenterology and Hepatology, Chia-yi Christian Hospital, Chia-Yi, Taiwan
| | - Ting-Yu Hu
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| |
Collapse
|
|
24
|
Kumar A, Tripathi SN, Mittal S, Abraham J, Makharia GK, Parshad R. Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation? Surg Laparosc Endosc Percutan Tech 2022; 32:299-304. [PMID: 35034067 DOI: 10.1097/sle.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Symptomatic evaluation using Eckardt score and achalasia-specific health-related quality-of-life and physiological evaluation using timed barium examination (TBE) and high-resolution manometry is integral to the diagnosis of achalasia. However, the correlation of physiological outcomes with symptomatic outcomes and their role in routine follow-up after laparoscopic Heller cardiomyotomy (LHCM) is controversial. In this study, we evaluated the role of physiological testing in achalasia patients undergoing LHCM and its correlation with symptomatic evaluation. MATERIALS AND METHODS Case records of patients undergoing LHCM for achalasia between January 2017 and March 2020 were reviewed for symptom scores (Eckardt score and achalasia-specific health-related quality-of-life) and physiological parameters [5-min column height on TBE and median integrated relaxation pressure (IRP) on high-resolution manometry]. Sixty-one patients with complete data in the preoperative period and on follow-up were included in the study. The data was analyzed for symptomatic and physiological outcomes and their correlation using paired t test and the Spearman correlation test. RESULTS At a median follow-up of 16 months following LHCM, there was a significant improvement in Eckardt score (7.03±1.53 to 0.93±1.10, P<0.001), achalasia-specific health-related quality-of-life (58.34±7.81 to 14.57±13.45, P<0.001), column height on TBE (115.14±46.9 to 27.89±34.31, P<0.001) and IRP (23.95±8.26 to 4.61±4.11, P<0.001). Eckardt score correlated significantly with achalasia-specific health-related quality-of-life scores preoperatively (ρ=0.410, P<0.001) and on follow-up (ρ=0.559, P<0.001). There was no correlation between symptomatic parameters and physiological parameters. CONCLUSIONS In patients of achalasia, LHCM leads to significant improvement in symptomatic and physiological parameters. Symptom scores correlate among themselves but not with physiological scores. Thus, physiological testing may not be needed for routine follow-up.
Collapse
Affiliation(s)
| | | | | | | | - Govind K Makharia
- Gastroenterology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | | |
Collapse
|
|
25
|
Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia? Surg Endosc 2022; 36:3932-3939. [PMID: 34494151 DOI: 10.1007/s00464-021-08712-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.
Collapse
Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50 Takashima-cho, Fuji, Shizuoka, 416-0951, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Tokorozawa, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| |
Collapse
|
|
26
|
Mohammed A, Garg R, Paranji N, Samineni AV, Thota PN, Sanaka MR. Pneumatic dilation for esophageal achalasia: patient selection and perspectives. Scand J Gastroenterol 2022; 57:650-659. [PMID: 35114867 DOI: 10.1080/00365521.2022.2034940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023]
Abstract
Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.
Collapse
Affiliation(s)
- Abdul Mohammed
- Department of Hospital Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Rajat Garg
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Neethi Paranji
- Department of Gastroenterology and Hepatology, MetroHealth Medical Center, Cleveland, OH, USA
| | - Aneesh V Samineni
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Prashanthi N Thota
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
|
27
|
Comparison of functional lumen imaging probe and high-resolution manometry to assess response after peroral endoscopic myotomy. Gastrointest Endosc 2022; 95:855-863. [PMID: 34979118 DOI: 10.1016/j.gie.2021.12.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/29/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIMS Outcomes after peroral endoscopic myotomy (POEM) are assessed clinically by the Eckardt score (ES) or objectively by high-resolution manometry (HRM) and functional lumen imaging probe (FLIP). This study compared HRM and FLIP to evaluate clinical response after POEM. METHODS This was a single tertiary center retrospective study of consecutive patients who underwent POEM for treatment-naive achalasia and with ≥6 months of follow-up. Baseline and follow-up testing in all patients included ES, HRM, and FLIP of the esophagogastric junction (EGJ). A normal post-POEM (or normalized) EGJ distensibility index (EGJ-DI) >2.8 mm2/mm Hg, maximum EGJ diameter (MxEGJD) ≥14 mm, and integrated relaxation pressure (IRP) <15 mm Hg were compared with a clinical response, defined as ES ≤3. RESULTS Eighty-seven patients (58% men, mean age 51 ± 17 years) were included. Overall clinical response by ES, IRP, MxEGJD, and EGJ-DI were 97.7%, 86.2%, 75.9%, and 92.0%, respectively. The sensitivity of a normal IRP (87.1% [95% confidence interval {CI}, 78.0-93.4]) was similar to the sensitivity of a normal MxEGJD (75.3% [95% CI, 64.7-84.0], P = .053) and normal EGJ-DI (91.8% [95% CI, 83.8%-96.6%], P = .39) after POEM to predict clinical response. However, the sensitivity of a normal post-POEM EGJ-DI was superior to a normal post-POEM MxEGJD (P = .001) to predict clinical response. There was no difference in the area under the curve of a normal MxEGJD or EGJ-DI to predict a normal IRP (P = .956) after POEM. CONCLUSIONS Normal FLIP metrics ≥6 months after POEM for achalasia show good to excellent sensitivity but are equivalent to a normalized IRP by HRM to predict clinical response by ESs. FLIP may be used as an alternative to HRM to assess lower esophageal sphincter response to POEM in these patients. (Clinical trial registration number: NCT02770859.).
Collapse
|
|
28
|
Patel DA, Yadlapati R, Vaezi MF. Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics. Gastroenterology 2022; 162:1617-1634. [PMID: 35227779 PMCID: PMC9405585 DOI: 10.1053/j.gastro.2021.12.289] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 12/03/2021] [Accepted: 12/12/2021] [Indexed: 12/13/2022]
Abstract
Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.
Collapse
Affiliation(s)
- Dhyanesh A. Patel
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| | - Rena Yadlapati
- Vanderbilt University Medical Center and Division of Gastroenterology, University of California San Diego
| | - Michael F. Vaezi
- Division of Gastroenterology, Hepatology and Nutrition, University of California San Diego
| |
Collapse
|
|
29
|
Hakimi T, Karimi R. Childhood esophageal achalasia: Case report from Afghanistan with literature review. Int J Surg Case Rep 2022; 94:107112. [PMID: 35658288 PMCID: PMC9118120 DOI: 10.1016/j.ijscr.2022.107112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/17/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance Esophageal achalasia is a motility disorder of the esophagus with unknown etiology characterized by the failure of lower esophageal sphincter relaxation. Diagnosis is made by barium esophagography, endoscopy, and esophageal manometery. Heller Esophagomyotomy along with Dor's fundoplication is the treatment of choice. Persisting undiagnosed cases may lead to malnutrition. Case presentation We present a case of an 8-year-old child suffering from dysphagia and regurgitation. The child was misdiagnosed and maltreated for the suspicion of respiratory tract and gastrointestinal problems in the local clinics. During this time, he remained unresponsive to the mentioned treatments, and the local physician advised him to have an upper gastrointestinal (GI) endoscopy, which revealed esophageal achalasia (EA). On admission to our pediatric surgery ward, the patient had coexistent parotitis, which was treated conservatively. Following recovery, the patient was prepared for surgery and underwent esophageal myotomy along with Dor's fundoplication. Clinical discussion Esophageal achalasia is rare in children, but poses major health challenges to children if left untreated. Symptomatic treatment may mask the actual picture of the problem and last for years. Following surgery and discharge from the hospital in a three-month follow-up interval of time, our patient exhibited full recovery, with gaining 4 kg weight. Conclusions Respiratory and gastrointestinal conditions with similar signs and symptoms should always be considered in differential diagnosis of esophageal achalasia, especially where there is no direct access to a pediatric specialized complex. On-time evaluation and treatment will further prevent children from malnutrition in long-lasting undiagnosed patients.
Esophageal achalasia is a motility disorder with unknown etiology. Esophageal achalasia is rare in children. Dysphagia and respiratory infection will mask the actual picture of the problem. Unprofessional symptomatic treatment for a long time is the main cause of undiagnosed patient and may lead to malnutrition.
Collapse
Affiliation(s)
- Turyalai Hakimi
- Department of Pediatric Surgery, Kabul University of medical science, Maiwand teaching hospital, Kabul, Afghanistan.
| | - Ramazan Karimi
- Department of Pediatric Surgery, Kabul University of medical science, Maiwand teaching hospital, Kabul, Afghanistan
| |
Collapse
|
|
30
|
Sanagapalli S, Plumb A, Sweis R. Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction. Neurogastroenterol Motil 2022; 34:e14322. [PMID: 35072303 DOI: 10.1111/nmo.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/26/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Timed barium swallow (TBS) is a recommended ancillary investigation in evaluation of esophagogastric junction (EGJ) obstruction, yet there are little data comparing esophageal stasis across subtypes. METHODS A retrospective cohort study was performed. All type III achalasia diagnosed between November 2016 and November 2020 were included, along with matched numbers of consecutive types I and II and conclusive EGJOO cases with concurrent TBS evaluation. Co-primary outcomes were TBS retention at 1 and 5 min. Secondary outcomes were symptoms and manometric metrics of EGJ function and peristaltic integrity. KEY RESULTS One hundred patients were included (25 each of types I-III and conclusive EGJOO). TBS retention measured by height and width at 1 and 5 min differed significantly across the four subtypes (p < 0.0001 all comparisons), with esophageal stasis tending to be significantly greater for types I and II achalasia (88% and 84% with >5 cm column at 5 min) compared to type III and EGJOO (24% and 8% with >5 cm column; p < 0.0001). Eckardt symptom severity was similar across subtypes (p = 0.30). Magnitude of esophageal stasis and integrated relaxation pressure (IRP) were uncorrelated (R = 0.21). In EGJOO, the number of swallows with intact peristalsis inversely correlated with barium column height (R = -0.49) and those with disordered peristalsis were more likely to have any residual barium at 5 min compared to those without disordered peristalsis (43% vs. 0%; p = 0.02). CONCLUSIONS & INFERENCES Timed barium swallow findings differed markedly with significantly less esophageal stasis in type III achalasia and EGJOO, despite similar symptom severity and no correlation between degree of emptying and IRP. Preservation of peristalsis may underlie this finding in EGJOO.
Collapse
Affiliation(s)
- Santosh Sanagapalli
- Centre for Swallowing & Oesophageal Disorders, St. Vincent's Hospital Sydney, Darlinghurst, New South Wales, Australia.,St Vincent's Clinical School, UNSW Sydney, Sydney, New South Wales, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
| |
Collapse
|
|
31
|
Madigan KE, Smith JS, Evans JK, Clayton SB. Elevated average maximum intrabolus pressure on high-resolution manometry is associated with esophageal dysmotility and delayed esophageal emptying on timed barium esophagram. BMC Gastroenterol 2022; 22:74. [PMID: 35189822 PMCID: PMC8859877 DOI: 10.1186/s12876-022-02165-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. METHODS A retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min. RESULTS AM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002). CONCLUSIONS Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.
Collapse
Affiliation(s)
- Katelyn E Madigan
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
| | - J Shawn Smith
- Department of Medicine, Prisma Health, Greenville School of Medicine, Greenville, USA
| | - Joni K Evans
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, USA
| | - Steven B Clayton
- Department of Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, USA
- Department of Medicine, Section on Gastroenterology, Greenville School of Medicine, Greenville, USA
| |
Collapse
|
|
32
|
Response to Sanagapalli and Sweis. Am J Gastroenterol 2022; 117:356-357. [PMID: 34928888 PMCID: PMC8816861 DOI: 10.14309/ajg.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
|
33
|
Abstract
Among recent advances in diagnostics for dysphagia and esophageal motility disorders is the update to the Chicago Classification (version 4.0) for interpretation of high-resolution manometry (HRM) and diagnosis of esophageal motility disorders. The update incorporates application of complementary testing strategies during HRM, such as provocative HRM maneuvers, and recommendation for barium esophagram or functional luminal imaging probe (FLIP) panometry to help clarify inconclusive HRM findings. FLIP panometry also represents an emerging technology for evaluation of esophageal distensibility and motility at the time of endoscopy.
Collapse
|
|
34
|
Pomenti S, Blackett JW, Jodorkovsky D. Achalasia: Diagnosis, Management and Surveillance. Gastroenterol Clin North Am 2021; 50:721-736. [PMID: 34717867 DOI: 10.1016/j.gtc.2021.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Achalasia is a rare chronic esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and abnormal peristalsis. This abnormal motor function leads to impaired bolus emptying and symptoms of dysphagia, regurgitation, chest pain, or heartburn. After an upper endoscopy to exclude structural causes of symptoms, the gold standard for diagnosis is high-resolution esophageal manometry. However, complementary diagnostic tools include barium esophagram and functional luminal impedance planimetry. Definitive treatments include pneumatic dilation, Heller myotomy with fundoplication, and peroral endoscopic myotomy.
Collapse
Affiliation(s)
- Sydney Pomenti
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - John William Blackett
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, 630 West 168th Street, Suite 3-401, New York, NY 10032, USA.
| |
Collapse
|
|
35
|
Dorsey YC, Song EJ, Leiman DA. Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders. Curr Gastroenterol Rep 2021; 23:29. [PMID: 34850300 DOI: 10.1007/s11894-021-00831-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD). RECENT FINDINGS Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.
Collapse
Affiliation(s)
- Y Claire Dorsey
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA
| | - Erin J Song
- Department of Medicine, Duke University, Durham, NC, USA
| | - David A Leiman
- Division of Gastroenterology, Duke University School of Medicine, Duke Clinical Research Institute, 200 Morris Street, Durham, NC, 27701, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
|
36
|
Evensen H, Småstuen MC, Schulz A, Kristensen V, Larssen L, Skattum J, Sandstad O, Hauge T, Medhus AW. One year comprehensive prospective follow-up of achalasia patients after peroral endoscopic myotomy. Ann Med 2021; 53:2225-2233. [PMID: 34806501 PMCID: PMC8805855 DOI: 10.1080/07853890.2021.2005253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/06/2021] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND AIMS Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but outcome evaluation has often been limited to Eckardt score (ES). The present study was aimed to improve knowledge about outcome evaluation and predictive outcome factors by performing a comprehensive objective evaluation of achalasia patients treated by POEM. METHODS This single centre prospective study reports outcome data 12 months after POEM in treatment-naive achalasia patients. A predefined follow-up protocol included ES, high resolution manometry, 24-h pH measurement, upper endoscopy and timed barium esophagogram (TBE). Univariate and multivariate regression analyses were performed to analyze association between post-POEM variables and identify predictive factors for objective outcome. RESULTS Fifty patients were included with a drop-out rate of <5%. ES, lower oesophageal sphincter pressures, TBE heights and maximal oesophageal diameter were all reduced after POEM (p < .001), and 28% (13/47) of the patients had a positive 24-h pH registration. An oesophageal diameter >3 cm after POEM was associated with treatment failure assessed by ES (p = .04) and TBE (p = .03). Advanced achalasia stage (p = .02) and long symptom duration (p = .04) were identified as independent predictive factors for poor outcome assessed by TBE. CONCLUSIONS The present study confirms that POEM is an efficient therapy for achalasia. The comprehensive objective evaluation after POEM demonstrates that long symptom duration and major changes in oesophageal anatomy at diagnosis imply poor treatment outcome, and a post-POEM dilated oesophagus is associated with treatment failure.Key messagesPeroral endoscopic myotomy (POEM) is established as a safe and effective therapy for achalasia.Timed barium esophagogram offers objective variables that are valuable in treatment response evaluation. Advanced achalasia stage and long symptom duration are predictive factors for poor objective treatment response after POEM.
Collapse
Affiliation(s)
- Helge Evensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Milada Cvancarova Småstuen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Diagnostic Physics, Norwegian Imaging Technology Research and Innovation Center (ImTECH), Oslo University Hospital, Oslo, Norway
| | - Vendel Kristensen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Unger-Vetlesen Institute, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Jorunn Skattum
- Department of Abdominal and Pediatric Surgery, Oslo University Hospital, Oslo, Norway
| | - Olav Sandstad
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Asle W. Medhus
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
|
37
|
DeWitt JM, Siwiec RM, Perkins A, Baik D, Kessler WR, Nowak TV, Wo JM, James-Stevenson T, Mendez M, Dickson D, Stainko S, Akisik F, Lappas J, Al-Haddad MA. Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response. Endosc Int Open 2021; 9:E1692-E1701. [PMID: 34790532 PMCID: PMC8589564 DOI: 10.1055/a-1546-8415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 12/02/2022] Open
Abstract
Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm 2 /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.
Collapse
Affiliation(s)
- John M. DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Robert M. Siwiec
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Anthony Perkins
- Department of Biostatistics, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Daniel Baik
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - William R. Kessler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Thomas V. Nowak
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - John M. Wo
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Toyia James-Stevenson
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Martha Mendez
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Destenee Dickson
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Sarah Stainko
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Fatih Akisik
- Department of Radiology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - John Lappas
- Department of Radiology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| | - Mohammad A. Al-Haddad
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, Indiana, United States
| |
Collapse
|
|
38
|
Clinical usefulness of esophageal high resolution manometry and adjunctive tests: An update. Dig Liver Dis 2021; 53:1373-1380. [PMID: 33994122 DOI: 10.1016/j.dld.2021.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/11/2022]
Abstract
High resolution manometry (HRM), developed from conventional manometry, is the gold standard for assessment of esophageal motor function worldwide. The Chicago Classification, now in its fourth iteration, is the modern standard for HRM categorization of esophageal motility disorders. The HRM protocol has expanded from the original 10 supine swallow standard, to include upright swallows, and provocative maneuvers such as multiple rapid swallows, rapid drink challenge and standardized test meal. Impedance has been incorporated into HRM for visualization of bolus clearance. Futhermore, barium radiography and functional lumen imaging probe complement HRM when evidence of esophagogastric junction obstruction is inconclusive. The biggest impact of HRM is in the improved diagnosis and subtyping of achalasia spectrum disorders, with implications on management. Spastic disorders and absent contractility are better characterized. Within the reflux spectrum, HRM provides definition of morphology and tone of the esophagogastric junction, and assesses integrity of esophageal body peristalsis, which have pathophysiologic implications for reflux and its clearance. HRM provides characterization of behavioral disorders such as supragastric belching and rumination syndrome, which can mimic reflux disease. Thus, HRM has revolutionized the evaluation of esophageal motor function, and has expanded the utility of esophageal manometry in clinical practice.
Collapse
|
|
39
|
Prediction of Esophageal Retention: A Study Comparing High-Resolution Manometry and Functional Luminal Imaging Probe Panometry. Am J Gastroenterol 2021; 116:2032-2041. [PMID: 34388142 PMCID: PMC8852837 DOI: 10.14309/ajg.0000000000001402] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/15/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION High-resolution manometry (HRM) is generally considered the primary method to evaluate esophageal motility; functional luminal imaging probe (FLIP) panometry represents a novel method to do so and is completed during sedated endoscopy. This study aimed to compare HRM and FLIP panometry in predicting esophageal retention on timed barium esophagram (TBE). METHODS A total of 329 adult patients who completed FLIP, HRM, and TBE for primary esophageal motility evaluation were included. An abnormal TBE was defined by a 1-minute column height >5 cm or impaction of a 12.5-mm barium tablet. The integrated relaxation pressure (IRP) on HRM was assessed in the supine and upright patient positions. Esophagogastric junction (EGJ) opening was evaluated with 16-cm FLIP performed during sedated endoscopy through EGJ-distensibility index and maximum EGJ diameter. RESULTS Receiver operating characteristic curves to identify an abnormal TBE demonstrated AUC (95% confidence interval) of 0.79 (0.75-0.84) for supine IRP, 0.79 (0.76-0.86) for upright IRP, 0.84 (0.79-0.88) for EGJ-distensibility index, and 0.88 (0.85-0.92) for maximum EGJ diameter. Logistic regression to predict abnormal TBE showed odds ratios (95% confidence interval) of 1.8 (0.84-3.7) for consistent IRP elevation and 39.7 (16.4-96.2) for reduced EGJ opening on FLIP panometry. Of 40 patients with HRM-FLIP panometry discordance, HRM-IRP was consistent with TBE in 23% while FLIP panometry was consistent with TBE in 78%. DISCUSSION FLIP panometry provided superior detection of esophageal retention over IRP on HRM. However, application of a complementary evaluation involving FLIP panometry, HRM, and TBE may be necessary to accurately diagnose esophageal motility disorders.
Collapse
|
|
40
|
Richter JE. Chicago Classification Version 4.0 and Its Impact on Current Clinical Practice. Gastroenterol Hepatol (N Y) 2021; 17:468-475. [PMID: 35462733 PMCID: PMC9021169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
High-resolution manometry (HRM) has revolutionized esophageal motility testing, and the evolving Chicago Classification has been critical in codifying HRM metrics and definitions of old and new motility disorders. The latest Chicago Classification (version 4.0) is the result of a working group of 52 members (10 women) from 20 countries. Two critical new elements are the expansion of the normal database from 75 to 469 healthy volunteers and the recommendation of ancillary function tests (timed barium esophagram, functional lumen imaging planimetry, and/or impedance) to help with inconclusive HRM metrics, especially in cases of suspected achalasia, esophagogastric junction outflow obstruction (EGJOO), and ineffective esophageal motility (IEM). Important changes relevant to clinical practice include (1) refinement of the diagnosis criteria for EGJOO, which now require elevated integrated relaxation pressure in an upright position along with primary symptoms of dysphagia/noncardiac chest pain and obstruction at the esophago-gastric junction; (2) exclusion of mechanical obstruction in cases of suspected distal esophageal spasm and hypercontractile esophagus; and (3) a shift to a more restrictive metric (>70% ineffective peristalsis) for a diagnosis of IEM. In addition, the working group urged caution in using treatments such as pneumatic dilation or myotomy, which can irreversibly destroy lower esophageal sphincter competency and peristalsis, as the natural history of EGJOO/hypercontractile esophagus is poorly understood and spontaneous symptom resolution is common. Future versions should address the routine use of impedance with HRM, the role of HRM in pharyngeal/upper esophageal sphincter diseases, and the need for better criteria to determine which subsets of spastic disorders warrant aggressive treatment, as is done with achalasia.
Collapse
Affiliation(s)
- Joel E Richter
- University of South Florida Morsani College of Medicine, Tampa, Florida
| |
Collapse
|
|
41
|
Kesavan P, Joshi S, Gercek Y. Intermittent neck swelling: an unusual presentation of achalasia cardia. BMJ Case Rep 2021; 14:e243229. [PMID: 34548296 PMCID: PMC8458346 DOI: 10.1136/bcr-2021-243229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 11/04/2022] Open
Abstract
Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.
Collapse
Affiliation(s)
- Piriyanga Kesavan
- General Surgery, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Shivani Joshi
- General Surgery, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| | - Yüksel Gercek
- General Surgery, Bedfordshire Hospitals NHS Foundation Trust, Bedford, UK
| |
Collapse
|
|
42
|
Oude Nijhuis RAB, Zaninotto G, Roman S, Boeckxstaens GE, Fockens P, Langendam MW, Plumb AA, Smout A, Targarona EM, Trukhmanov AS, Weusten B, Bredenoord AJ. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United European Gastroenterol J 2021; 8:13-33. [PMID: 32213062 PMCID: PMC7005998 DOI: 10.1177/2050640620903213] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Achalasia is a primary motor disorder of the oesophagus characterised by absence of peristalsis and insufficient lower oesophageal sphincter relaxation. With new advances and developments in achalasia management, there is an increasing demand for comprehensive evidence-based guidelines to assist clinicians in achalasia patient care. METHODS Guidelines were established by a working group of representatives from United European Gastroenterology, European Society of Neurogastroenterology and Motility, European Society of Gastrointestinal and Abdominal Radiology and the European Association of Endoscopic Surgery in accordance with the Appraisal of Guidelines for Research and Evaluation II instrument. A systematic review of the literature was performed, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Recommendations were voted upon using a nominal group technique. RESULTS These guidelines focus on the definition of achalasia, treatment aims, diagnostic tests, medical, endoscopic and surgical therapy, management of treatment failure, follow-up and oesophageal cancer risk. CONCLUSION These multidisciplinary guidelines provide a comprehensive evidence-based framework with recommendations on the diagnosis, treatment and follow-up of adult achalasia patients.
Collapse
Affiliation(s)
- R A B Oude Nijhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College, London, UK
| | - S Roman
- Digestive Physiology, Hôpital Edouard Herriot, Lyon, France
| | - G E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Centre for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - P Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - M W Langendam
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - A A Plumb
- Centre for Medical Imaging, University College London, London, UK
| | - Ajpm Smout
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - E M Targarona
- Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - A S Trukhmanov
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
|
43
|
Tomizawa Y, Mahmud N, Dasher K, Triggs JR, Saumoy M, Falk GW, Ginsberg GG. Type II achalasia is associated with a comparably favorable outcome following per oral endoscopic myotomy. Dis Esophagus 2021; 34:5974939. [PMID: 33180122 DOI: 10.1093/dote/doaa107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/07/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023]
Abstract
Per oral endoscopic myotomy (POEM) is a safe and effective treatment for esophageal motility disorder in treatment-naïve patients as well as salvage therapy. Though type II achalasia, compared to other subtypes, is reported to have a more favorable outcome with pneumatic dilation (PD) or Heller myotomy (HM), it is unclear whether achalasia subtype predicts symptom response to POEM. We aimed to evaluate whether type II achalasia is associated with a comparably favorable outcome following POEM. We performed a retrospective review of patients with esophageal motility disorder who were referred for POEM from April 2014 to June 2017. The main outcome was clinical success based on Eckardt score ≤3 and its association with subtype and safety. A total of 63 patients (mean age 51 years [SD 15]; 63% male) underwent a total of 68 POEMs with median of 263 days follow-up. Of these, 45 (71.3%) patients were type II achalasia. In all, 29 (46%) patients were treatment-naïve and 34 (54%) patients had previous endoscopic or surgical therapy including botulinum toxin injection in 16 (25%), PD in 10 (16%), both botulinum toxin injection and PD in 8 (13%) and HM in 3 (5%). Technical success was 100% and clinical success was achieved in 51 (81%) patients. The rate of clinical success was higher in patients with type II achalasia compared to the other subtypes (88.9% vs. 61.1% [P = 0.028]) and type II achalasia patients required fewer redo POEM (2.2% vs. 22.2% [P = 0.021]). Multivariate logistic regression analysis demonstrated the positive prediction of clinical success for type II achalasia following POEM (P = 0.046). As observed with PD and HM, type II achalasia was associated with a favorable clinical outcome following POEM.
Collapse
Affiliation(s)
- Yutaka Tomizawa
- Division of Gastroenterology, Harborview Medical Center, University of Washington, Seattle, WA, USA.,Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nadim Mahmud
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Dasher
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph R Triggs
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Monica Saumoy
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary W Falk
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
|
44
|
Gong EJ, Na HK, Ahn JY, Jung KW, Kim DH, Choi KD, Song HJ, Jung HY. Prospective evaluation of the efficacy of peroral endoscopic myotomy in patients with achalasia. Medicine (Baltimore) 2021; 100:e26248. [PMID: 34115014 PMCID: PMC8202605 DOI: 10.1097/md.0000000000026248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 01/04/2023] Open
Abstract
Peroral endoscopic myotomy (POEM) is an endoscopic alternative to surgical myotomy in patients with achalasia. This study aimed to evaluate the efficacy and clinical outcomes of POEM.A total of 20 patients with achalasia who underwent POEM between October 2016 and November 2017 were prospectively recruited. The intraoperative esophagogastric junction distensibility index (mm2/mm Hg) was measured pre- and post-myotomy using an endoluminal functional lumen imaging probe. Clinical response was defined as Eckardt score ≤3. Health-related quality of life was measured by the 36-item short-form health survey score.POEM was successfully completed in all cases. The median procedure time was 68.5 minutes (range 50.0-120.0), and the median myotomy length was 13 cm (range 11-18). Major adverse events were encountered in 2 cases. Overall, clinical responses were observed in all patients during a median follow-up of 11.9 months (range 1.2-26.2). Postoperative esophagogastric junction distensibility index was significantly higher than baseline (from 1.3 [range 0.8-6.9] to 6.3 [range 25-19.2], P < .001). The median Eckardt scores were decreased after POEM (5 [range 2-11] to 1 [range 0-3], P < .001), and the 36-item short-form health survey score was also improved significantly after POEM (67.5 [range 34.5-93.9] to 85.7 [range 53.4-93.3], P = .004).POEM is an effective treatment for achalasia, based on the improvement of both symptoms and objective measures.Clinicaltrial.gov NCT02989883.
Collapse
Affiliation(s)
- Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| |
Collapse
|
|
45
|
Pesce M, Sweis R. Advances and caveats in modern achalasia management. Ther Adv Chronic Dis 2021; 12:2040622321993437. [PMID: 33786159 PMCID: PMC7958157 DOI: 10.1177/2040622321993437] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022] Open
Abstract
Achalasia is a rare esophageal motility disorder characterized by the incomplete
relaxation of the lower esophageal sphincter (LES) and impaired peristaltic
activity. The advent of high-resolution manometry (HRM) and the rapidly evolving
role of therapeutic endoscopy have revolutionized the approach to the diagnosis
and management of achalasia patients in the last decade. With advances in HRM
technology and methodology, fluoroscopy and EndoFlip, achalasia can be
differentiated into therapeutically meaningful phenotypes with a high degree of
accuracy. Further, the newest treatment option, per-oral endoscopic myotomy
(POEM), has become a staple therapy following the last 10 years of experience,
and recent randomized trials appear to show no difference between POEM, graded
pneumatic dilatation and surgical Heller myotomy in terms of short- and
long-term efficacy or complication rate. On the other hand, how treatment
outcomes are measured as well as the risk of reflux following therapy remain
areas of contention. This review aims to summarize the recent advancements in
achalasia testing and therapy, describes the recent randomized clinical trials
as well as their potential setbacks, and touches on the future of personalizing
achalasia treatment.
Collapse
Affiliation(s)
- Marcella Pesce
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Rami Sweis
- University College London Hospital, GI Services, 235 Euston Rd, London, NW1 2BU, UK
| |
Collapse
|
|
46
|
Blonski W, Kumar A, Feldman J, Richter JE. Timed barium swallow for assessing long-term treatment response in patients with achalasia: Absolute cutoff versus percent change - A cross-sectional analytic study. Neurogastroenterol Motil 2021; 33:e14005. [PMID: 32996266 DOI: 10.1111/nmo.14005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/02/2020] [Accepted: 09/07/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Timed barium swallow (TBS) assesses esophageal emptying before and after therapy in patients with achalasia. Our aim was to compare the accuracy of percent change in barium height with traditional absolute cutoff of <5 cm on post-treatment TBS. MATERIALS AND METHODS Consecutive patients with treatment naïve achalasia treated with either PD, HM, or POEM between 1/2012 and 7/2017 were eligible for inclusion. The accuracy of percent change in pre- and post-treatment barium height at 5 minutes versus an absolute <5 cm cutoff for assessing treatment response was assessed using the receiver operating curve analysis (ROC). RESULTS Eighty-one patients met the inclusion criteria. The median percent change in barium heights at five minutes in patients who did not improve was 6 percent increase (n = 10; mean 10.6) versus 78 percent decrease (n = 71; mean 64) in patients who improved (P = 0.0001). The AUC for percent change in TBS 5 minutes height was 76% (95% CI 48% to 90%), and a 3% decrease from baseline as a cutoff had a sensitivity of 60% and specificity of 99%. The AUC for post-treatment TBS 5 minutes height was 79% (95% CI 53% to 91%), and the 5 cm cutoff had a sensitivity of 70% and specificity of 75%. CONCLUSIONS The results show that 3% percent improvement in pre- and post-treatment barium height at 5 minutes rather than absolute cutoff value of <5 cm on post-treatment TBS is a better indicator of treatment success in achalasia patients. These findings indicate the need for reassessment of tools to identify treatment response.
Collapse
Affiliation(s)
- Wojciech Blonski
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ambuj Kumar
- Research Methodology and Biostatistics Core, Office of Research, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - John Feldman
- Department of Radiology, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Joel E Richter
- Joy McCann Culverhouse Center for Swallowing Disorders, Division of Digestive Diseases and Nutrition, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| |
Collapse
|
|
47
|
Slone S, Kumar A, Jacobs J, Velanovich V, Richter JE. Accuracy of Achalasia Quality of Life and Eckardt scores for assessment of clinical improvement post treatment for achalasia. Dis Esophagus 2021; 34:5900199. [PMID: 32875315 DOI: 10.1093/dote/doaa080] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/23/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023]
Abstract
Achalasia Quality of Life (ASQ) and Eckardt scores are two patient-reported instruments widely used to assess symptom severity in achalasia patients. ASQ is validated and reliable. Although Eckardt is commonly used, it has not been rigorously assessed for validity or reliability. This study aims to evaluate (i) the accuracy of Eckardt and ASQ for assessing improvement post-treatment (predictive validity), (ii) accuracy of Eckardt and ASQ for assessing improvement post-treatment with pneumatic dilatation (PD) versus surgical myotomy (predictive validity), and (iii) convergent validity of Eckardt and ASQ tools. Patients with achalasia treated between 2011 and 2018 were eligible. Both instruments were administered by telephone. Treatment failure was determined by the review of medical records by two clinicians. The predictive ability of ASQ and Eckardt instruments in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as area under the curve (AUC). A total of 106 patients met inclusion criteria with 39 PD, 51 Heller myotomy, and 16 per-oral endoscopic myotomy. A review of medical records and esophageal testing revealed 13 failures (12%). AUC for Eckardt was 0.96 (95% confidence interval [CI] 0.87-0.99] and ASQ 0.97 (95% CI 0.92-0.99). The Eckardt cutoff 4, and ASQ, cutoff 15, were 94% and 87% accurate in identifying treatment successes versus failures, respectively. The correlation coefficient between the two tools was 0.85. In conclusions, (i) ASQ and Eckardt scores are valid and reliable tools to assess symptom severity in achalasia patients, (ii) both instruments accurately classify treatment successes versus failures, and (iii) the choice of tool should be informed by the physicians and patients' values and preferences and repeat physiologic testing may be reserved for treatment failures with either instrument and patients classified, as treatment successes may be spared routine physiologic testing in the long term.
Collapse
Affiliation(s)
| | | | - John Jacobs
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
| | - Vic Velanovich
- Joy McCann Culverhouse Center for Swallowing Disorders.,Division of General Surgery, Morsani College of Medicine University of South Florida, Tampa, Florida, USA
| | - Joel E Richter
- Division of Digestive Diseases and Nutrition.,Joy McCann Culverhouse Center for Swallowing Disorders
| |
Collapse
|
|
48
|
Sanagapalli S, Plumb A, Maynard J, Leong RW, Sweis R. The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate. Neurogastroenterol Motil 2020; 32:e13928. [PMID: 32578341 DOI: 10.1111/nmo.13928] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/27/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Timed barium swallow (TBS) is used to objectively measure response following achalasia therapy; however, findings can be discordant with symptoms. We hypothesized that measurement of surface area of the residual barium column would improve its utility in measuring outcome. METHODS In a single-center cohort, achalasia patients undergoing therapy between September 2015-2016 who had TBS were included. Four metrics of emptying were studied: Post-therapy residual barium (a) absolute height and (b) surface area and percentage reduction in (c) residual height (%H) and (d) surface area (%SA) compared to pretherapy. Metrics were evaluated against symptom response (Eckardt score). KEY RESULTS Twenty-four achalasics (median age 43 year; 13 males) were included; 14 received pneumatic dilatation, and 10 had peroral endoscopic myotomy. Treatment resulted in significant reduction in median Eckardt score (7 to 1; P = .03), mean residual barium column height (14.7 ± 8.7 to 7.9 ± 6.0 cm; P = .01) and surface area (52.7 ± 43.5 to 24.5 ± 23.6 cm2 ; P = .02). There were 4 (17%) initial non-responders (Eckardt > 3). % SA was best at discriminating between responders and non-responders (area under curve 0.85 ± 0.08; sensitivity 100%, specificity 80%). Concordance with symptomatic response following therapy was 83% when using 45% as the cutoff for surface area reduction compared to pretherapy. Eight patients whose static barium height was discordant with symptoms became concordant when % SA was used as a measure of response. CONCLUSIONS & INFERENCES Change in barium surface area is a superior measure of esophageal emptying and better correlates with treatment response than the conventional 5-minute barium height in defining objective response to achalasia therapy.
Collapse
Affiliation(s)
- Santosh Sanagapalli
- GI Physiology Unit, University College London Hospital, London, UK.,St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Plumb
- GI Physiology Unit, University College London Hospital, London, UK
| | - John Maynard
- GI Physiology Unit, University College London Hospital, London, UK
| | - Rupert W Leong
- Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Rami Sweis
- GI Physiology Unit, University College London Hospital, London, UK
| |
Collapse
|
|
49
|
Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc 2020; 53:638-645. [PMID: 33212547 PMCID: PMC7719430 DOI: 10.5946/ce.2020.223] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Peroral endoscopic myotomy (POEM) is one of the most clinically successful tunnel-based minimally invasive endoscopic treatments. The classic indications of POEM include achalasia of all types, including failed prior treatments, and expanded indications include the non-achalasia esophageal motility disorders, such as esophagogastric junction outflow obstruction, diffuse esophageal spasm, and jackhammer esophagus. For achalasia treatment, POEM has achieved a comparable surgical efficacy and a safety outcome and, therefore, has emerged as a first-line treatment. For non-achalasia esophageal motility disorders, POEM has also shown high clinical response rates. The complication rate of POEM for esophageal motility disorders is low and most complications are managed with conservative treatment. Currently, POEM is a representative procedure of natural orifice transluminal endoscopic surgery, which has shown a good clinical efficacy with low complication rates for esophageal motility disorders including achalasia. However, further studies are needed to treat non-achalasia motility disorder via POEM.
Collapse
Affiliation(s)
- Jun Young Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
|
50
|
Rieder E, Fernandez-Becker NQ, Sarosiek J, Guillaume A, Azagury DE, Clarke JO. Achalasia: physiology and diagnosis. Ann N Y Acad Sci 2020; 1482:85-94. [PMID: 33140485 DOI: 10.1111/nyas.14510] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/17/2020] [Accepted: 09/22/2020] [Indexed: 12/18/2022]
Abstract
Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.
Collapse
Affiliation(s)
- Erwin Rieder
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jerzy Sarosiek
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, Texas
| | - Alexandra Guillaume
- Gastrointestinal Motility Center, Renaissance School of Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Dan E Azagury
- Minimally Invasive & Bariatric Surgery, Stanford University School of Medicine, Palo Alto, California
| | - John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| |
Collapse
|