The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate

Exploring the neural mechanisms underlying achalasia: A study of functional connectivity and regional brain activity

BACKGROUND AND AIMS

The pathophysiology of achalasia, which involves central nuclei abnormalities, remains unknown. We investigated the resting-state functional MRI (rs-fMRI) features of patients with achalasia.

METHODS

We applied resting-state functional MRI (rs-fMRI) to investigate the brain features in patients with achalasia (n = 27), compared to healthy controls (n = 29). Focusing on three regions of interest (ROIs): the dorsal motor nucleus of the vagus (DMV), the nucleus ambiguus (NA), and the nucleus of the solitary tract (NTS), we analyzed variations in resting-state functional connectivity (rs-FC), fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo).

RESULTS

Achalasia patients demonstrated stronger functional connectivity between the NA and the right precentral gyrus, left postcentral gyrus, and left insula. No significant changes were found in the DMV or NTS. The fMRI analysis showed higher rs-FC values for NA-DMV and NA-NTS connections in achalasia patients. Achalasia patients exhibited decreased fALFF values in the NA, DMV, and NTS regions, as well as increased ReHo values in the NA and DMV regions. A positive correlation was observed between fALFF values in all six ROIs and the width of the barium meal. The NTS fALFF value and NA ReHo value displayed a positive correlation with integrated relaxation pressure (IRP), while the ReHo value in the right precentral gyrus showed an inverse correlation with the height of the barium meal.

CONCLUSIONS

Abnormal rs-FC and regional brain activity was found in patients with achalasia. Our study provides new insights into the pathophysiology of achalasia and highlights the potential of rs-fMRI in improving the diagnosis and treatment of this condition.

[Therapy of esophageal motility disorders]

Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.

Modern Achalasia: Diagnosis, Classification, and Treatment

Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. As a consequence of the esophageal outflow obstruction, achalasia patients present with clinical symptoms of dysphagia, chest pain, weight loss, and regurgitation of indigested food. Other less specific symptoms can also present including heartburn, chronic cough, and aspiration pneumonia. The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. Other tools have also emerged to help define achalasia severity and which can be used as objective measures of response to therapy including the timed barium esophagogram and the functional lumen imaging probe. Such diagnostic innovations, along with the increased awareness by clinicians and patients due to the availability of alternative therapeutic approaches (laparoscopic and robotic Heller myotomy, and peroral endoscopic myotomy) have radically changed the natural history of the disorder. Herein, we report the most recent advances in the diagnosis, classification, and management of esophageal achalasia and underline the still-grey areas that needs to be addressed by future research to reach the goal of personalizing treatment.

How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia

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.

[Therapy of esophageal motility disorders]

Esophageal motility disorders are diseases in which there are malfunctions of the act of swallowing due to a change in neuromuscular structures. The main symptom is therefore dysphagia for solid and/or liquid foods, often accompanied by symptoms such as chest pain, regurgitation, heartburn, and weight loss. Esophageal manometry is the gold standard in diagnostics. Endoscopy and radiology serve to exclude inflammatory or malignant changes. With the introduction of high-resolution esophageal manometry (HRM), the diagnosis of esophageal motility disorders has improved and led to a new classification with the Chicago Classification, which has been modified several times in the last decade, most recently in 2020 with the Chicago Classification v4.0. Compared to the previous version 3.0, there are some important changes that are presented based on the most important esophageal motility disorders in everyday clinical practice.

Rapid Drink Challenge During High-resolution Manometry for Evaluation of Esophageal Emptying in Treated Achalasia

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.

Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial

BACKGROUND

Achalasia is a rare benign esophageal motor disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES). The treatment of achalasia is not curative, but rather is aimed at reducing LES pressure. In patients who have failed noninvasive therapy, surgery should be considered. Myotomy with partial fundoplication has been considered the first-line treatment for non-advanced achalasia. Recently, peroral endoscopic myotomy (POEM), a technique that employs the principles of submucosal endoscopy to perform the equivalent of a surgical myotomy, has emerged as a promising minimally invasive technique for the management of this condition.

AIM

To compare POEM and laparoscopic myotomy and partial fundoplication (LM-PF) regarding their efficacy and outcomes for the treatment of achalasia.

METHODS

Forty treatment-naive adult patients who had been diagnosed with achalasia based on clinical and manometric criteria (dysphagia score ≥ II and Eckardt score > 3) were randomized to undergo either LM-PF or POEM. The outcome measures were anesthesia time, procedure time, symptom improvement, reflux esophagitis (as determined with the Gastroesophageal Reflux Disease Questionnaire), barium column height at 1 and 5 min (on a barium esophagogram), pressure at the LES, the occurrence of adverse events (AEs), length of stay (LOS), and quality of life (QoL).

RESULTS

There were no statistically significant differences between the LM-PF and POEM groups regarding symptom improvement at 1, 6, and 12 mo of follow-up (P = 0.192, P = 0.242, and P = 0.242, respectively). However, the rates of reflux esophagitis at 1, 6, and 12 mo of follow-up were significantly higher in the POEM group (P = 0.014, P < 0.001, and P = 0.002, respectively). There were also no statistical differences regarding the manometry values, the occurrence of AEs, or LOS. Anesthesia time and procedure time were significantly shorter in the POEM group than in the LM-PF group (185.00 ± 56.89 and 95.70 ± 30.47 min vs 296.75 ± 56.13 and 218.75 ± 50.88 min, respectively; P = 0.001 for both). In the POEM group, there were improvements in all domains of the QoL questionnaire, whereas there were improvements in only three domains in the LM-PF group.

CONCLUSION

POEM and LM-PF appear to be equally effective in controlling the symptoms of achalasia, shortening LOS, and minimizing AEs. Nevertheless, POEM has the advantage of improving all domains of QoL, and shortening anesthesia and procedure times but with a significantly higher rate of gastroesophageal reflux.

Symptomatic and Physiological Outcomes Following Laparoscopic Heller Myotomy for Achalasia Cardia: Is There a Correlation?

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.

Timed barium swallow: Esophageal stasis varies markedly across subtypes of esophagogastric junction obstruction

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.

Morphologic Changes in Esophageal Body Movement During Bolus Transport After Peroral Endoscopic Myotomy in Type III Achalasia

Background/Aims

The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia.

Methods

Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed.

Results

The MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group.

Conclusions

POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.

Achalasia in the Elderly: Diagnostic Approach and a Proposed Treatment Algorithm Based on a Comprehensive Literature Review

Achalasia is not uncommonly diagnosed in elderly patients and its incidence and prevalence are growing in this population. However, a scarcity of studies has assessed the typical pathophysiological and clinical features of the disease as well as the effectiveness and safety of the various therapeutic options in elderly populations. Botulinum toxin injection has been used for achalasia treatment since 1994 and is traditionally considered the preferred treatment for fragile elder patients. However, recently more evidence has become available regarding the safety and effectiveness of pneumatic balloon dilation (BD), laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) in elderly patients with achalasia. In the current review we present the current literature on this topic with a focus on the clinical presentation of achalasia in the elderly and manometric features thereof, as well as summarize the effectiveness and safety of the various therapeutic options. Furthermore, we propose a practical management algorithm as a means to guide the treatment of future cases. We recommend that a conservative/BTI approach should be adopted in the fragile unfit patient. In the elderly fit patient, the treatment decision should be based on the achalasia type, patient preference and the available expertise, similar to the approach adopted for the non-elderly population.

Diagnosis and Management of Achalasia: Updates of the Last Two Years

Achalasia is a rare neurodegenerative disorder causing dysphagia and is characterized by abnormal esophageal motor function as well as the loss of lower esophageal sphincter (LES) relaxation. The assessment and management of achalasia has significantly progressed in recent years due to the advances in high-resolution manometry (HRM) technology along with the improvements and innovations of therapeutic endoscopy procedures. The recent evolution of HRM technology with the inclusion of an adjunctive test, fluoroscopy, and EndoFLIP has enabled more precise diagnoses of achalasia to be made and the subgrouping into therapeutically meaningful subtypes. Current management possibilities include endoscopic treatments such as Botulinum toxin injected to the LES and pneumatic balloon dilation. Surgical treatment includes laparoscopic Heller myotomy and esophagectomy. Furthermore, in recent years, per oral endoscopic myotomy (POEM) has established itself as a principal endoscopic therapeutic alternative to the traditional laparoscopic Heller myotomy. The latest randomized trials report that POEM, pneumatic balloon dilatation, and laparoscopic Heller's myotomy have comparable effectiveness and complications rates. The aim of the current review is to provide a practical clinical approach to dysphagia and to shed light on the most recent improvements in diagnostics and treatment of achalasia over the last two years.

Advances and caveats in modern achalasia management

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.