Trends in diagnoses after implementation of the Chicago classification for esophageal motility disorders (V3.0) for high-resolution manometry studies

Association of esophageal motility disorder symptoms with Chicago classification versions 3.0 and 4.0 using high-resolution esophageal manometry: A single-center experience from Saudi Arabia

BACKGROUND

Esophageal motility disorders (EMDs) can significantly impact patients' quality of life. The Chicago Classification (CC) was developed as a robust framework to enable clinicians to better understand and classify the nature of motility disorders. Previous studies have primarily focused on the CC version 3.0 (CCv3.0), and data regarding the correlation between symptoms and CC version 4.0 (CCv4.0) in the Saudi Arabian population are lacking. This study aimed to assess the correlation between symptoms and CCv3.0 and CCv4.0 using high-resolution esophageal manometry (HRM) in Saudi Arabia, to evaluate the diagnostic performance of both classifications.

METHODS

A total of 182 patients presenting with esophageal symptoms were included in this study. HRM was performed to assess esophageal motility, and patients' reported symptoms were recorded. The association between HRM findings and symptomatic variables was analyzed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

Variability was observed in the diagnostic performance of symptomatic variables for major EMDs. CCv4.0 demonstrated a higher sensitivity for dysphagia than CCv3.0; however, it exhibited lower sensitivity to atypical gastroesophageal reflux disease (GERD) symptoms. Noncardiac chest pain (NCCP) exhibited the highest specificity and PPV, whereas typical GERD symptoms showed lower specificity.

CONCLUSION

CCv4.0 demonstrated potential improvements in sensitivity for dysphagia, but lower sensitivity for atypical GERD symptoms, compared with CCv3.0. These insights provide guidance for clinicians in Saudi Arabia and contribute to understanding the diagnostic performance of CCv3.0 and CCv4.0.

Neoadjuvant Therapy Versus Upfront Surgery for Patients With Clinical Stage 2 or 3 Esophageal Squamous Cell Carcinoma: A Cost-Effectiveness Analysis

BACKGROUND

Although neoadjuvant therapy followed by surgery (NT) is the standard of care for esophageal cancer in Western countries, upfront surgery (US) followed by adjuvant therapy (when indicated) still is commonly used in Asia to minimize overtreatment. This study investigated the cost-effectiveness of NT versus US for patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Patients with a diagnosis of ESCC between 2010 and 2015 were divided into NT or US according to the intention to treat. Two propensity score-matched groups of patients with clinical stage 2 (135 pairs) or stage 3 (194 pairs) disease were identified and compared in terms of overall survival (OS) and direct costs incurred within 3 years after diagnosis.

RESULTS

The esophagectomy rates after NT were 82% for stage 2 and 88% for stage 3 disease. Compared with US, surgery after NT was associated with higher R0 resection rates, a lower number of dissected lymph nodes, and similar postoperative mortality. On an intention-to-treat analysis, stage 3 patients who received NT had a significantly better 3-year OS rate (45%) than those treated with US (37%) (p = 0.029) without significant cost increases (p = 0.89). However, NT for clinical stage 2 disease neither increased costs nor improved 3-year OS rates (47% vs 47%; p = 0.88). At a willingness-to-pay level of US$50,000 per life-year, the probability of NT being cost-effective was 92% for stage 3 versus 59% for stage 2 ESCC.

CONCLUSION

Because of its higher cost-effectiveness, NT is preferable to US for patients with clinical stage 3 ESCC, but US remains a viable option for stage 2 disease.

Evaluation of Esophageal Motility and Lessons from Chicago Classification version 4.0

PURPOSE OF REVIEW

Chicago Classification has standardized clinical approach to primary esophageal motility disorders. With new clinical data and advancing treatments, Chicago Classification has undergone multiple revisions to reflect updated findings and enhance diagnostic accuracy. This review will describe the recently published Chicago Classification version 4.0 (CCv4.0), which aimed to enhance diagnostic characterization and limit overdiagnosis of inconclusive esophageal motility diagnoses.

RECENT FINDINGS

Key revisions outlined in CCv4.0 include (1) a modified standardized HRM study protocol performed in supine and upright positions, (2) recommended ancillary testing and manometric provocation for inconclusive manometric diagnoses (3) the required presence of obstructive symptoms for conclusive diagnoses of esophagogastric junction outflow obstruction, distal esophageal spasm and hypercontractile esophagus, and (4) requirement of confirmatory testing for esophagogastric junction outflow obstruction. These key modifications aim to improve diagnostic accuracy and consistency of clinically relevant esophageal motility disorders, and subsequently clinical outcomes.

Integrated Relaxation Pressure Classification and Probe Positioning Failure Detection in High-Resolution Esophageal Manometry Using Machine Learning

High-resolution esophageal manometry is used for the study of esophageal motility disorders, with the help of catheters with up to 36 sensors. Color pressure topography plots are generated and analyzed and using the Chicago algorithm a final diagnosis is established. One of the main parameters in this algorithm is integrated relaxation pressure (IRP). The procedure is time consuming. Our aim was to firstly develop a machine learning based solution to detect probe positioning failure and to create a classifier to automatically determine whether the IRP is in the normal range or higher than the cut-off, based solely on the raw images. The first step was the preprocessing of the images, by finding the region of interest-the exact moment of swallowing. Afterwards, the images were resized and rescaled, so they could be used as input for deep learning models. We used the InceptionV3 deep learning model to classify the images as correct or failure in catheter positioning and to determine the exact class of the IRP. The accuracy of the trained convolutional neural networks was above 90% for both problems. This work is just the first step in fully automating the Chicago Classification, reducing human intervention.

Population trends in achalasia diagnosis and management: a changing paradigm

The Chicago Classification of esophageal motility disorders improved the differentiation of achalasia subtypes and tailored treatment. Heller myotomy (HM) and pneumatic dilation are two established treatments for achalasia. Peroral endoscopic myotomy (POEM) has become a third definitive option and is on the rise. Using the National Inpatient Sample (NIS) database, we evaluated patients hospitalized with achalasia and associated surgical and endoscopic interventions from 2013 to 2017 and compared patients undergoing HM versus POEM. The NIS database was queried to include patients with achalasia. Patients who underwent HM, POEM (only 2017 due to lack of distinct procedure code in 2013), pneumatic dilation, or esophagectomy were identified. Adverse events during the hospitalization were also queried using diagnosis codes. From 2013 to 2017, patients hospitalized with achalasia increased from 16 850 to 19 485. There were reductions in the number of esophageal dilations (10.6-5.4%, P < 0.001) and HM (18.7-13.1%, P < 0.001). In 2017, 580 POEMs were performed. Compared with patients undergoing HM in 2017, patients who had POEM had higher mean age > 64 (P = 0.004), Charlson comorbidity index (P < 0.001), disease severity (P < 0.001), and likelihood of mortality (P < 0.001). There were no differences in length of stay, mortality, or total costs between the HM and POEM groups. Patients hospitalized with achlasia increased from 2013 to 2017, possibly due to the growth and accessibility of high-resolution esophageal manometry. As expertise in POEM increases, the number of POEM performed is anticipated to rise with possible further reductions in other treatment modalities for achalasia.