Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©

Imaging following endoscopic and surgical treatment of achalasia

Achalasia is an esophageal motility disorder characterized by absent esophageal peristalsis associated with failure of relaxation of the lower esophageal sphincter (LES). Patients with achalasia may present with long-standing and slowly progressive dysphagia to solids and liquids, heartburn, regurgitation, refractory reflux symptoms and noncardiac chest pain. The esophagram and the timed barium swallow are useful imaging studies that may contribute to the diagnosis of achalasia and may be used to determine improvement after treatment. Esophagography is also ideally suited to evaluate potential post treatment complications. Treatment options for achalasia aim to disrupt the high-pressure LES to improve esophageal emptying, improve symptoms and prevent further dilatation of the esophagus. The most common treatment options currently include esophageal botulinum toxin (Botox) injections, pneumatic dilatation, Heller myotomy (often performed in conjunction with a fundoplication) and peroral endoscopic myotomy. Potential complications of these procedures may include intramural dissection, leak, scarring and fibrosis of the lower esophagus, strictures and problems related to gastroesophageal reflux and its associated complications. Radiologists must be aware of expected findings and potential complications following these procedures for timely and accurate diagnoses. The purpose of this paper is to describe treatment options for achalasia, illustrate expected imaging findings as well as imaging findings of potential early and long-term complications following treatment for achalasia.

High-Resolution Manometry With Solid Provocative Test in Patients With Mid-Thoracic and Epiphrenic Esophageal Diverticula

BACKGROUND

The number of studies exploring esophageal motility disorders using high-resolution manometry (HRM) in patients with esophageal diverticula (ED) is limited. The goal of this study was to describe motility disorders using HRM in patients with ED and assess the added value of provocative testing in these patients.

METHODS

Patients with ED who underwent HRM between 2010 and 2022 were retrospectively included. HRM findings were compared based on single water swallows (SWS), and provocative testing with solid food swallows in the upright seated position, using both ManoView and Medical Measurement Systems software. We also calculated median pressure slopes during the compartmentalization phase.

KEY RESULTS

Sixteen of the 39 included patients had mid-ED and 23 had lower ED. Twenty (51.3%) patients had motility disorders based on SWS, including 7 (18%) with achalasia and 3 (7.7%) with esophagogastric junction obstruction. No significant differences in esophageal motility disorders were observed in relation to the location of the ED. Solid food swallows were performed in 29 (74%) patients leading to a change in the HRM diagnosis in 7 (24.1%), all of whom showed elevated IRP. Median pressure slopes during the compartmentalization phase (n = 30) were elevated in patients both with and without motility disorders.

CONCLUSION AND INFERENCES

Half of the patients with mid- or lower ED had motility disorders on HRM. Adding solid food swallows during HRM in patients with ED improves the manometric diagnosis. Results suggest abnormal distensibility in these patients, indicated by elevated pressure slope, regardless of the presence of associated motility disorders.

Long-term Prognosis and Prognostic Factors in Ineffective Esophageal Motility

Background/Aims

Ineffective esophageal motility is the most frequent disorder of esophageal peristalsis. Symptoms may include dysphagia, chest pain, and heartburn. Our aims are to evaluate the long-term prognosis and determine if provocative tests during high-resolution esophageal manometry could predict the prognosis.

Methods

We retrospectively assessed high resolution manometries performed between 2015-2018 in adult patients. Symptoms were evaluated at baseline and at follow-up (median 39 months later) using the impact dysphagia questionnaire (IDQ-10), where a score ≥ 7 defined dysphagia, the gastroesophageal reflux disease questionnaire (GerdQ), where a score ≥ 9 defined symptoms of reflux disease and if the subject had chest pain ≥ once a week. Chicago classifications version 3.0 and 4.0 were used. The contractile reserve was assessed by identifying whether esophageal peristalsis normalized or not on solid bolus swallows and a rapid drink challenge was included.

Results

Nine hundred and eighty investigations performed during the study period; 114 patients (11.6%) were identified with ineffective esophageal motility. The final study cohort consisted of 33 patients of which 42% had dysphagia at follow-up and 25% had chest pain at least once a week, 46% had reflux symptoms. Patients who normalized motility on solid bolus swallows reported less dysphagia upon follow-up (P = 0.012), nevertheless reported similar proportions of chest pain (P = 0.632), and reflux (P = 0.514). There were no associations between having dysphagia, chest pain, or reflux at follow-up, and abnormal findings on the rapid drink challenge (P > 0.05 for all).

Conclusions

Patients with ineffective esophageal motility continue to experience long-term esophageal symptoms at follow-up. Provocative tests seem to have the potential to partly predict the long-term prognosis of dysphagia.

Functional Lumen Imaging Probe Measurement Post-Pneumatic Dilation in Clinically Relevant Esophagogastric Junction Outlet Obstruction

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.

Heller myotomy in patients with prior endoscopic interventions vs the treatment-naïve

BACKGROUND

Definitive palliation for achalasia is surgical myotomy; however, patients frequently undergo endoscopic treatments prior to myotomy. Surgeons may perceive myotomy to be more challenging after prior treatments, due to scarring and fusion of dissection planes, but outcomes compared to the treatment-naïve remain unclear. Hence, we compared institutional Heller myotomy outcomes in patients who underwent pre-myotomy endoscopic treatments to those who did not.

METHODS

From 1/1/2010 to 1/1/2020, 436 patients underwent Heller myotomy for achalasia at Cleveland Clinic, 101 (23%) of whom had prior endoscopic intervention(s): 39 (39%) pneumatic dilation, 57 (56%) botulinum toxin injection, and 5 (4.9%) both (Prior group). Propensity score matching generated two groups of 101 pairs. Short-term outcomes and longitudinal postoperative symptom palliation (Eckardt score ≤ 3), esophageal emptying at five minutes, and reintervention were assessed and compared with the treatment-naïve (Naïve group).

RESULTS

There were no statistically significant differences in operative time, mucosal perforation, or length of stay between Prior and Naïve groups (P > .12). At 5 years, the probability of symptom palliation was 83% in the Prior Group vs 81% in the Naïve Group (P = .63) and complete esophageal emptying 23% vs 32% (P = .095). The cumulative number of reinterventions per 100 patients at 10 years was 7.9 in the Prior Group and 4.8 in the Naïve Group (P = .13).

CONCLUSION

The perception of increased complexity of Heller myotomy in patients with prior endoscopic interventions does not translate to stastically significant differences in short- or long-term outcomes when compared to the treatment-naïve. A subtle longitudinal pattern of suboptimal esophageal emptying and increased reintervention for patients with prior intervention(s), suggests that, when possible, up-front myotomy may be preferred.

Additional Diagnostic Yield of Ambulatory 24-h High Resolution Manometry With Impedance in Patients With Non-Cardiac Chest Pain or Non-Obstructive Dysphagia

BACKGROUND

In patients with non-cardiac chest pain (NCCP) and non-obstructive dysphagia (NOD), standard esophageal high resolution manometry (HRM) with water swallows and/or solid meals may miss intermittent dysmotility. To what extent prolonged 24 h-measurements may increase the diagnostic sensitivity is currently unclear.

METHODS

75 patients (47 female, 58 ± 16 years) with NCCP and/or NOD underwent standard HRM (single water swallows plus rice meal) and ambulatory 24-h-HRM with impedance. Results were analyzed according to Chicago Classification v3.0 for water-swallow-HRM; adapted criteria were used for rice-meal and 24-h-HRM. Patients were followed by chart review.

KEY RESULTS

Contractility parameters obtained by different HRM procedures always correlated (R > 0.27, p < 0.05). During 24 h-measurements, all parameters showed circadian variability (p < 0.001). In comparison with water-swallow-HRM, rice-meal-HRM markedly increased the proportion of patients diagnosed with achalasia III, esophagogastric outlet obstruction with spastic features, distal esophageal spasm, or hypercontractility (10.7% vs. 21.3%, p = 0.039). The diagnostic gain regarding spastic and/or hypercontractile disorders was further increased by 24-h-HRM (61.3% of patients, p < 0.001). In 11 out of 21 patients with normal results in both water-swallow- and rice-meal-HRM (15% of total cohort), 24-h-HRM detected a major motor disorder. Results of 24-h-HRM altered treatment recommendations in 41 patients (54%).

CONCLUSIONS&INFERENCES

24-h-HRM revealed spastic and/or hypercontractile esophageal motor disorders in about 60% of patients with NCCP/NOD and markedly improved diagnostic yield compared with standard HRM, probably partly due to the observed circadian variability of esophageal motility. 24-h-HRM findings frequently altered treatment recommendations, but the ultimate clinical consequences of the increased diagnostic yield have to be examined further.

Three-to-six month post-POEM timed barium esophagram can predict esophageal contents and may stratify aspiration risk on follow-up EGD

BACKGROUND

Peroral endoscopic myotomy (POEM) is an increasingly utilized endoscopic therapy for achalasia. When undergoing esophagogastroduodenoscopy (EGD), patients with a diagnosis of achalasia may receive endotracheal intubation (EI) to reduce the risk of aspiration. The risk of aspiration on post-POEM EGD should be reduced due to improved esophageal emptying. Despite history of myotomy, treated achalasia patients frequently receive EI on follow-up EGD increasing costs, procedural time, and potential risks from anesthesia. We determined if timed barium esophagram (TBE) findings three to six months after POEM predict the presence of esophageal contents on follow up endoscopy which may indicate aspiration risk.

METHODS

We identified achalasia patients who underwent POEM from September 2021 to October 2023 and had both a follow-up TBE and EGD three to six months later. At our institution, all achalasia patients are instructed to avoid solid oral intake (liquids allowed) for 2 days prior to pre-and post-POEM EGD. Predictors of esophageal contents were identified and receiver operating characteristic (ROC) curves were constructed to determine column heights that correspond to the presence of esophageal contents.

RESULTS

We identified 48 patients meeting inclusion criteria. Increasing barium column height at 5 min was associated with liquid/solid esophageal contents on EGD (OR: 1.36; p = 0.004). The receiver operating characteristics curve for esophageal contents demonstrated an area under the curve of 0.85 at 7 cm. Passage of a 13 mm tablet was inversely associated with the presence of esophageal contents (OR: 0.03; p = 0.002).

CONCLUSION

In post-POEM achalasia patients, follow-up TBE at 3-6 months demonstrating a 5-minute barium column height of less than 7.0 cm and passage of a 13 mm barium tablet may predict an esophagus free of liquid/solids during follow-up EGD after a 2-day solid fast. This study adds to our knowledge that TBE findings are a good predictor of esophageal emptying post-POEM, and may be used to predict which patients may be at risk of having residual esophageal contents and therefore need EI.

Defining Pharyngeal and Upper Esophageal Sphincter Disorders on High-Resolution Manometry-Impedance: The Leuven Consensus

INTRODUCTION

The Leuven Consensus provides a classification scheme for the diagnosis of pharyngeal and upper esophageal sphincter (UES) motor disorders using metrics derived from pharyngeal high-resolution manometry-impedance (P-HRM-I).

METHODS

Twenty-six experts with broad multidisciplinary backgrounds contributed their knowledge and experience to this initiative via a formal deliberative Delphi process. Guidance on a swallow assessment protocol as well as diagnostic criteria for UES dysfunction and pharyngeal contractile dysfunction is provided.

RESULTS

For UES dysfunction, the stepwise evaluation of UES and intrabolus pressure metrics under increasing bolus volume and/or viscosity conditions is used to confirm failure of manometric relaxation and opening of the UES region. For pharyngeal contractile dysfunction, the evaluation of contractile metrics is used to define pharyngeal hypocontractility or hypercontractility.

CONCLUSION

These recommendations complement routine instrumental investigations and provide a standardized process, criteria, and nomenclature for P-HRM-I assessment of patients reporting symptoms of oropharyngeal dysphagia.

Diaphragmatic Flutter Disease: Key Findings in Esophageal Manometry and Biofeedback Treatment

BACKGROUND

Diaphragmatic flutter (DF) is a rare condition characterized by involuntary contractions of the diaphragmatic muscle, often accompanied by accessory respiratory muscle contractions. Symptoms can include epigastric pulsations, abdominal pain, and reflux. Diagnosis is challenging, and treatment is based on individual cases. This study presents the first case series of DF assessed using high-resolution esophageal manometry (HREM), electromyography (EMG), and plethysmography belts, and the symptomatic improvement through biofeedback therapy.

METHODS

This case series includes patients with refractory abdominal spasms referred to the digestive motility department from 2018 to 2024.

RESULTS

Two patients were diagnosed with DF using HREM, which reveals a characteristic pattern of oscillating increases in intragastric pressure, repetitive crural diaphragm spasms, and pharyngeal contraction during abdominal spasms. Symptomatic control was achieved following abdomino-thoracic biofeedback (ATB) therapy by plethysmography belts.

CONCLUSIONS

High-resolution esophageal manometry offers a reliable, non-invasive method for diagnosis of DF, presenting a specific manometric pattern. ATB appears to be an effective treatment for DF, suggesting that voluntary but unconsciously initiated movement disorders may contribute to the condition.

European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management

INTRODUCTION

Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

METHODS

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

RESULTS

Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

CONCLUSION

These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

Factors predicting insufflation-related events in peroral endoscopic myotomy procedures

BACKGROUND

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic landscape for esophageal achalasia, offering efficacy comparable to that of surgery with the convenience of an endoscopic approach. With the growing popularity of POEM, insufflation-related adverse events (AEs) present unique challenges that have been widely discussed in the literature. This study aimed to investigate the safety profiles and risk factors associated with insufflation-related events in patients undergoing POEM in endoscopy suites.

METHODS

This retrospective analysis included 100 consecutive patients with achalasia treated by POEM at our institute between March 2016 and October 2022. All procedures were performed in an endoscopy suite and employed carbon dioxide insufflation and general anesthesia with endotracheal intubation and positive-pressure ventilation. Variations in cardiopulmonary dynamics, intraprocedural AEs, and postoperative recovery were documented.

RESULTS

All procedures were successfully performed, with an average POEM duration of 92.3 min and an average anesthesia duration of 108.4 min. Of note, 1 major AE involving an esophageal leak and requiring endoscopic stenting was observed, along with a 27% incidence of minor AEs. Insufflation-related events, manifesting as capnoperitoneum, subcutaneous emphysema, or capnomediastinum, were identified in 48% of cases, but none required additional interventions or extended hospitalization. A peak inspiratory pressure increase of ≥20% was identified as the only predictor of insufflation-related events.

CONCLUSION

Performing POEM in an endoscopy suite can generally be considered safe from major AEs related to insufflation. Monitoring peak inspiratory pressure for a ≥20% increase may be an early indicator of other potential insufflation-related events.

An indication-based analysis of the yield and findings of esophageal high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. While studies have previously reported on HRM findings in patients with dysphagia and/or chest pain, we sought to compare the yield and findings of HRM based on different indications for motility testing.

METHODS

A retrospective study was performed including all successful HRM studies performed at two tertiary medical centers between 2018 and 2023. The indication was categorized as either: (1) dysphagia; (2) GERD evaluation; (3) non-cardiac chest pain; (4) epigastric pain; (5) regurgitation/vomiting; or (6) prior to esophageal surgery. Motility disorders were diagnosed as per the Chicago Classification, version 4.0.

RESULTS

A total of 768 patients were included (mean age 55.5 +/- 17.3; 56.2% female). The most common indications were dysphagia (368, 47.9%) and prior to reflux testing (267, 34.8%). Normal motility was found in 417 (54.3%) patients while a motility disorder was diagnosed in 351 (45.7%) subjects. A major motility disorder was found in 178 (23.2%) cases, with achalasia in 82 (10.7%) patients. HRM diagnoses significantly differed based on the indication for testing (p < 0.001), with major motility disorders and achalasia being most commonly diagnosed when performed for dysphagia and recurrent regurgitation/vomiting. The indication affected the likelihood of having any motility disorder (p = 0.010), a major motility disorder (p < 0.001), a disorder of EGJ Outflow (p < 0.001), and achalasia (p < 0.001).

CONCLUSIONS

The indication for HRM testing affects the likelihood of having a motility disorder including achalasia. The highest yield is in patients being evaluated for dysphagia and regurgitation/vomiting.

Pharyngeal electrical stimulation favorably modifies healthy human pharyngoesophageal function: a randomized trial using high-resolution manometry impedance

Despite positive clinical evidence for the effects of pharyngeal electrical stimulation (PES) on swallowing performance in disease, it remains unknown which specific swallow characteristics improve. Using high-resolution manometry impedance (HRMI) with pressure flow analysis (PFA), we aimed to assess the effects of PES on normal swallow function and to evaluate the impact of pharyngeal length variability on electrode placement. As part of a prospective randomized controlled trial (RCT), 20 asymptomatic volunteers were randomly assigned to 3 days of PES or SHAM treatment. HRMI assessments were conducted at baseline (during which pharyngeal length measurements were acquired) and repeated at 1-2 h, and at 24-72 h following PES or SHAM treatment. Twenty healthy adults [10 males, median age: 28.0 (interquartile range, IQR 23.8-45.0) yr, age range: 20-65 yr] participated in this RCT. We developed an objective, standardized method of catheter placement based on pharyngeal length measurements. Over 3 days, the median stimulation intensity of PES was 11 mA. When compared with the SHAM group, the PES group scored better on multiple pharyngeal and esophageal metrics resulting in improved global swallow function values 1-2 h after treatment (P = 0.029). One day later, most of these beneficial effects were no longer present. This study suggests that PES can temporarily alter swallow function in healthy individuals. Functional reserve in healthy individuals may be further enhanced by PES. In the majority of volunteers, electrode position needed to be adjusted 1-3 cm to account for variations in pharyngeal length.NEW & NOTEWORTHY Pharyngeal electrical stimulation (PES) positively influences clinical swallow-outcomes in patients with neurogenic dysphagia. Its effect on the underlying swallowing physiology remains unknown. Our study evaluated this effect of PES in healthy individuals using high-resolution manometry impedance. PES showed short-term improved pharyngeal contractility, upper esophageal sphincter relaxation, proximal esophageal contractility and bolus flow, resulting in improved swallowing. One day later, most of these beneficial effects were no longer present as expected in already intact swallow systems.

Long-term clinical evaluation of a decade with peroral endoscopic myotomy at a single European tertiary center

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia with compelling midterm efficacy. In this study, we analyzed the long-term efficacy, sought predictors of failure, and comprehensively assessed post-POEM reflux.

METHODS

We performed a retrospective analysis of a prospective database of patients undergoing POEM at a high-volume center from December 2012 to June 2023. Patients who had completed a 3-month follow-up were included. Efficacy was assessed at 3, 6, and 8 years using the Eckardt score (ES). An ES ≤2 was considered treatment success. At 3 months, gastroscopy, manometry, 24-hour pH monitoring, and fluoroscopy were performed, and gastroscopy was repeated at 2 and 3 years. At each visit, patients were assessed for reflux symptoms and quality of life.

RESULTS

From 496 included patients, 3-, 6-, and 8-year follow-ups were completed in 302, 115, and 40 patients, respectively. The treatment success rates at 3, 6, and 8 years according to the Kaplan-Meier analysis were 90.2% (95% confidence interval [CI], 87.2-93.3), 82.3% (95% CI, 77.3-87.6), and 73.5% (95% CI, 64.8-83.5), respectively. Year of procedure was the only predictor of outcome. Fifty-three patients (10.7%) encountered failure or recurrence. Treatment success of redo-POEM (n = 20) at 1 year was significantly lower (62.9% [95% CI, 44.3-89.2] vs 96.9% [95% CI, 95.3-98.5], P < .001). At 3 months, 40.4% of patients had reflux esophagitis (RE), 43.6% of patients had an acid exposure time >4.5%, 39.2% of patients were using proton pump inhibitors (PPIs), but only 24.2% had reflux symptoms. At 2 to 3 years, 50.8% of patients took PPIs, whereas 39.6% were symptomatic. RE decreased to 20.2% at 6 years.

CONCLUSIONS

The treatment success of POEM declines over time but remains sufficiently high in the long term. Experience with the procedure improves the outcome. Gastroesophageal reflux affects almost half of patients early after POEM and decreases substantially over time together with a rise in PPI use.

Peroral endoscopic myotomy for complex achalasia and the POEM difficulty score: An update

Objectives

We present an update on the (peroral endoscopic myotomy (POEM) difficulty score [PDS] by introducing a novel knife with waterjet functionality.

Methods

This is a retrospective review of patients who underwent POEM between May 2018 and July 2023 at the Kingston Health Sciences Center. Demographic and procedural variables were compared using descriptive and inferential statistics.

Results

One hundred thirty-nine consecutive POEMs were included in the study. Seventy-four (56.7% male; aged 56.7 ± 16.5 years) complex achalasia (CA) and 65 (55.4% female; aged 47.3 ± 20.2 years) non-CA POEM procedures were performed. PDS correlates moderately with procedural efficiency with a correlation coefficient of 0.595 (Spearman's p < 0.001). The mean efficiency for non-CA was 3.3 ± 1.2 min/cm compared to CA as follows: type III 3.3 ± 1.3 min/cm; prior myotomy 5.3 ± 2.3 min/cm; ≧4 prior procedures 4.0 ± 1.7 min/cm; sigmoid type 5.2 ± 2.4 min/cm. The median PDS for non-CA was 1 (1-5). In comparison, the median PDS for CA is as follows: type III 3 (2-4); prior myotomy 4 (3-5); ≧4 prior procedures 3 (1.25-4); sigmoid type 3 (2-4). PDS excluding the presence of spastic contractions correlated better with procedural velocity, with a correlation coefficient of 0.645 (Spearman's p < 0.001).

Conclusions

PDS continues to moderately correlate with procedural efficiency using the novel knife. The presence of spastic contractions correlated poorly with procedural efficiency. Thus, it may be omitted in further studies.

Beyond visualizing the bird beak: esophagram, timed barium esophagram and manometry in achalasia and its 3 subtypes

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.

Ex-vivo mechano-structural characterization of fresh diseased human esophagus

The esophagus, the tube-like organ responsible for transporting food from the pharynx to the stomach, operates as a highly mechanical structure, exhibiting complex contraction and distension patterns triggered by neurological impulses. Despite the critical role of mechanics in its function and the need for high-fidelity models of esophageal transport, mechanical characterization studies of human esophagus remain relatively scarce. In addition to the paucity of studies in human specimens, the available results are often scattered in terms of methodology and scope, making it difficult to compare findings across studies and thereby limiting their use in computational models. In this work, we present a detailed passive-mechanical and structural characterization of the esophageal muscular layers, excised from short esophageal segments obtained from live patients with varied clinical presentations. Specifically, we conducted uniaxial and planar biaxial extension tests on the smooth muscle layers, complemented by pre- and post-testing structural characterization via histological imaging. Unlike existing studies, our experimental results on passive behavior are discussed in the context of physiological relevance (e.g., physiological stretches, and activity-inhibiting pathologies), providing valuable insights that guide the subsequent modeling of the esophagus' mechanical response. As such, this work provides new insights into the passive properties of the fresh human esophagus, expands the existing database of mechanical parameters for computational modeling, and lays the foundation for future studies on active mechanical properties. STATEMENT OF SIGNIFICANCE: Understanding the mechanical properties of the esophagus is crucial for developing accurate models of its function and suitable replacements. This study provides insights into the passive mechanical behavior of fresh human esophageal tissue, enhancing our understanding of how it responds to stretching under physiological conditions. By characterizing the properties of different esophageal layers, obtained from esophagectomy specimens with various presentations, and considering their relevance to both normal and abnormal functioning, this work addresses the gap in ex-vivo human esophagus studies. The findings emphasize the importance of contextually analyzing experimental results within physiological parameters and suggest avenues for future research to further refine our understanding of esophageal mechanics, paving the way for improved diagnostic and therapeutic approaches in managing esophageal disorders.

Effect of Thickened Fluids on Swallowing Function in Oropharyngeal Dysphagia: Impact of Shear Rheology and Disorder Subtype

INTRODUCTION

Fluid thickeners used in the management of oropharyngeal dysphagia exhibit non-Newtonian shear-thinning rheology, impacting their viscosity during deglutition. This study investigated how the rheological properties of thickened fluids affect pharyngeal swallowing parameters in patients with oropharyngeal motor disorders diagnosed by pharyngeal high-resolution manometry impedance (P-HRM-I).

METHODS

Seventy-two patients (18-89 years) referred for P-HRM-I were diagnostically assessed with a 10 mL thin bolus. In 57 of the patients, 10 mL swallows of two moderately thick formulations-xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC)-were also tested. The XG and CMC fluids had equivalent empirical thickness but different viscosity at pharyngeal phase shear rates: XG 87 mPa.s (83-91) versus CMC mean 157 mPa.s (148-164) at 300 s-1. Standard metrics of pharyngeal and upper esophageal sphincter (UES) function were derived from P-HRM-I recordings and analyzed to characterize patients into one of four disorder subtypes: (i) No Disorder, (ii) UES Disorder, (iii) Pharyngeal Disorder, and (iv) Combination UES/Pharyngeal Disorder. Impedance recordings also assessed pharyngeal bolus transit.

RESULTS

Patients with a Combination UES/Pharyngeal Disorder were most likely to have abnormal bolus transit (82%, p < 0.001). Increasing bolus viscosity significantly influenced UES residual pressure, UES opening area, and post-swallow residue. Patients with UES Disorder exhibited pronounced increases in UES residual pressure with CMC compared to XG. Pharyngeal contractility was unaffected by viscosity changes. Post-swallow residue increased with CMC, particularly in patients with a Combination Disorder. Case-by-case analysis revealed individual variability in response to the different viscosities.

CONCLUSION

The rheological properties of thickened fluids significantly affect swallowing function, with these effects dependent upon the disorder subtype.

Primary Peristalsis Is the Dominant Mechanism of Refluxate Clearance Following Gastroesophageal Reflux

BACKGROUND

Refluxate volume and pH drop following gastroesophageal reflux are mostly cleared by peristalsis. We evaluated the roles of primary volume clearing peristaltic wave (VCPW), secondary VCPW, post-reflux swallow-induced peristaltic wave (PSPW), and late primary peristaltic wave (LPPW) in refluxate clearance.

METHODS

We retrospectively analyzed pH-impedance studies performed off therapy in 40 patients with typical esophageal symptoms. Mechanism of refluxate clearance was evaluated for each reflux episode (primary VCPW vs. secondary VCPW vs. none), as well as presence of PSPW, LPPW when PSPW was absent, and pH recovery with each mechanism. Per-episode and per-patient analyses determined the dominant mechanism of refluxate clearance and pH recovery.

RESULTS

Of 958 reflux episodes, 88% were acidic. A primary VCPW was the dominant mechanism for volume clearance (48.4% acid, 47.8% non-acid reflux episodes), and ≥ 50% pH recovery (58.7%). Of reflux episodes lacking pH recovery, PSPW resulted in ≥ 50% pH recovery in 40.2%, and LPPW in 60.9%. In logistic regression models, primary peristaltic wave (primary VCPW, PSPW, or LPPW) had the highest likelihood of pH recovery in per-episode analysis (OR 2.1, CI 1.3-3.0, p < 0.001), and in per-patient analysis (OR 11.0, CI 1.5-20.5, p = 0.025), among which primary VCPW was the most effective (OR 3.4, CI 1.5-7.7, p = 0.003).

CONCLUSIONS

A primary peristaltic wave from a swallow, either in the form of a VCPW, PSPW, or LPPW, is the dominant mechanism of pH recovery after gastroesophageal reflux. When a primary VCPW does not correct pH drop, PSPW, and LPPW are equivalent salvage mechanisms for pH recovery.

Correlation of the VFSS Esophageal Screen to High-Resolution Esophageal Manometry

OBJECTIVE

The videofluoroscopic swallow study (VFSS) is an evaluation of the anatomy and physiology of swallowing, and often includes a screening evaluation of the esophagus. How the esophageal screen translates to esophageal pathology remains unknown. The purpose of this study was to determine if abnormal esophageal clearance (EC) on VFSS correlates with esophageal function on high-resolution esophageal manometry (HREM).

MATERIALS AND METHODS

This is a retrospective review of 115 adult patients who underwent both VFSS with esophageal screen and HRM. EC on VFSS was scored with the modified barium swallow impairment profile (MBSImP) component 17. Motility was characterized using HRM metrics according to the Chicago Classification Version 4.0 (CCv4.0). Predictive metrics were calculated for the esophageal screen.

RESULTS

An EC score o greater than or equal to 1 had a sensitivity of 66%, specificity of 57%, PPV of 52%, NPV of 70%, and OR of 2.55 (p = 0.027). EC weakly correlated with incomplete bolus clearance (rho = 0.331, p = 0.0004) and did not correlate with bolus transit time (rho = 0.17, p = 0.105).

CONCLUSIONS

The esophageal screen as characterized by the MBSImP is not an effective predictor of esophageal function on HREM as defined by the CCv4.0. Future work may focus on a defining a standardized VFSS protocol for the esophageal screen and potentially a more nuanced assessment of esophageal findings on VFSS that may enhance the sensitivity of the modality to motility disorders.

LEVEL OF EVIDENCE: 3

Endoscopic Prediction of Achalasia: Putting the CART Before the CARS

BACKGROUND AND AIMS

Endoscopy can detect features indicative of esophageal dysmotility, but standardized approaches for diagnosing achalasia based on these findings remain limited. Recently, the CARS score was developed to address this gap. This study aimed to evaluate the diagnostic utility of endoscopy in identifying achalasia, using the STARD framework and current reference standards.

METHODS

Adult patients with esophageal symptoms were prospectively enrolled from 2018 to 2023 and evaluated using endoscopy, esophageal manometry, FLIP panometry, and barium esophagram. The CARS score was assigned to endoscopic videos by two raters blinded to other clinical details. The diagnostic accuracy of the CARS score for predicting achalasia, based on Chicago Classification v4.0, was assessed through two interpretation methods: binary cutoffs for the total score and a classification tree model.

RESULTS

316 patients were included: 115 patients with achalasia (36%), 113 with normal motility (36%), and 88 with other manometric findings (28%). A CARS score ≥ 4 demonstrated 72% sensitivity and 99% specificity for achalasia, while a score ≥ 3 had 83% sensitivity and 96% specificity. The optimal classification tree had three levels (resistance score at the top, followed by anatomy and content scores, with hernia presence at the bottom) and had a sensitivity of 90% and a specificity 92% for achalasia.

CONCLUSION

Endoscopy can accurately identify achalasia with high specificity using the CARS score. While motility testing to confirm an achalasia diagnosis remains essential prior to therapy, a high CARS score may help in the early identification of achalasia, especially in settings where motility testing is not readily available.

Peroral endoscopic myotomy in spastic esophageal disorders: Clinical outcomes and optimal approaches

OBJECTIVES

The efficacy and safety of peroral endoscopic myotomy (POEM) for spastic esophageal disorders (SED), including type III achalasia, distal esophageal spasm (DES), and jackhammer esophagus (JE), remain uncertain due to its rarity. This study aimed to evaluate the clinical outcomes and optimal strategies for managing SED.

METHODS

A retrospective analysis was conducted on patients who underwent POEM for SED between March 2014 and December 2023. Myotomy was tailored to target spastic segments in all cases. For type III achalasia, the myotomy extended into the gastric cardia, while for DES and JE, the procedure either preserved the lower esophageal sphincter (LES) or included a gastric myotomy. Outcomes assessed included procedural details, technical and clinical success, adverse events, and the incidence of gastroesophageal reflux disease (GERD) post-POEM. Clinical success was defined as an Eckardt score of ≤3.

RESULTS

Among 2938 POEM procedures, 106 (3.6%) were for SED. The cohort included 58 patients (54.8%) with type III achalasia, 24 (22.6%) with DES, and 24 (22.6%) with JE. The technical success rate was 100%, with clinical success rates of 98.1% at 2-3 months and 92.6% at 1 year. Erosive esophagitis occurred in 27.7% at 2-3 months and 16.1% at 1 year. LES-preserving POEM for DES and JE showed comparable efficacy to POEM with gastric myotomy, with a trend toward reduced GERD incidence.

CONCLUSION

Peroral endoscopic myotomy is an effective treatment for all types of SED. LES-preserving POEM is a viable strategy for treating DES and JE, offering comparable efficacy, while potentially minimizing GERD risk.

Esophageal high-resolution manometry and 24 h pH-impedance monitoring normative values in patients with obesity candidate for bariatric and metabolic surgery

Obesity is linked to increased risk of gastroesophageal reflux disease (GERD) and esophageal motility disorders, both of which may impact outcomes in metabolic and bariatric surgery (MBS). GERD pathophysiology in obesity includes elevated intraabdominal pressure and altered esophagogastric junction (EGJ) function. High resolution manometry (HRM) and 24-h esophageal pH-impedance (MII-pH) monitoring are vital in evaluating GERD, yet normative values specific to populations with obesity are limited, risking misdiagnosis if lean data are used. This study establishes normative HRM and MII-pH values in asymptomatic individuals with obesity, compared to normal-weight controls, to guide accurate diagnosis and treatment. A retrospective analysis was conducted on asymptomatic patients with obesity (BMI ≥ 30) and normal-weight controls (BMI 20-25) who underwent HRM and MII-pH prior to MBS between 2015 and 2024. Exclusion criteria included GERD symptoms, esophagitis, and prior gastrointestinal surgery. Key HRM parameters (LES pressure, EGJ morphology) and MII-pH metrics (acid exposure time, reflux episodes) were recorded and analyzed. Of the 96 patients with obesity and 25 normal-weight participants, significant differences in HRM and MII-pH results were observed. Individuals with obesity showed increased intra-gastric pressure, gastroesophageal pressure gradient, and higher acid exposure time. While LES pressure and EGJ morphology were similar to controls, participants with obesity exhibited distinct reflux patterns, especially postprandial, suggesting obesity-specific physiological changes. This study establishes normative HRM and MII-pH values for asymptomatic individuals with obesity, highlighting critical differences from normal-weight controls. Obesity-specific diagnostic criteria are essential for accurate GERD diagnosis, particularly for MBS candidates, to improve management and predict potential postoperative complications.

The Los Angeles-B esophagitis is a conclusive diagnostic evidence for gastroesophageal reflux disease: the validation of Lyon Consensus 2.0

Background and Aims

Recently, Lyon Consensus 2.0 recommended Los Angeles (LA)-B esophagitis as conclusive evidence and LA-A esophagitis as borderline evidence for gastroesophageal reflux disease (GERD). This study aimed to investigate the diagnostic value of LA-B and LA-A esophagitis.

Methods

Patients with typical reflux symptoms who underwent endoscopy examination and received acid-suppressive therapy from two tertiary hospitals [the First Affiliated Hospital of Sun Yat-sen University (Guangzhou, P. R. China) and the Third People's Hospital of Chengdu (Chengdu, P. R. China)] were retrospectively included. Acid-suppression response rates, endoscopy results, motility, and reflux parameters were compared between patients with different grades of esophagitis.

Results

In total, 401 patients were enrolled, among whom 254 were without reflux esophagitis (RE), 51 had LA-A esophagitis, 44 had LA-B esophagitis, and 52 had LA-C/D esophagitis. Patients with LA-B esophagitis and LA-C/D esophagitis had significantly higher acid-suppressive response rates than non-RE patients (P < 0.05), whereas no significant difference was found between patients with LA-A esophagitis and non-RE patients (non-RE vs LA-A vs LA-B vs LA-C/D: 52.4% vs 70.6% vs 75.0% vs 82.7%). Among patients with LA-A esophagitis, those with a number of reflux episodes that exceeded 80 per day (90.0% vs 52.4%, P = 0.044) or hypotensive esophagogastric junction (72.4% vs 52.4%, P = 0.040) had significantly higher acid-suppressive response rates than non-RE patients.

Conclusions

LA-B esophagitis can be regarded as conclusive evidence for GERD and initiate acid-suppressive therapy. LA-A esophagitis did not establish a definite GERD diagnosis alone. When combined with adjunctive or supportive evidence, the acid-suppressive therapy response rate of LA-A esophagitis improved.

Accuracy of COuGH RefluX Score as a Predictor of Gastroesophageal Reflux Disease (GERD) in Mexican Patients with Chronic Laryngopharyngeal Symptoms: A Cross-Sectional Study

Background/Objectives: Gastroesophageal reflux disease (GERD) is associated with extraesophageal syndromes that require an objective assessment of abnormal acid exposure to establish the diagnosis. The COuGH RefluX score has been proposed as a diagnostic tool for GERD in patients with chronic laryngopharyngeal symptoms. The aim of the study was to evaluate the diagnostic performance of the COuGH RefluX score in the Mexican population. Methods: A cross-sectional study was conducted in patients with chronic laryngopharyngeal symptoms. Patients with cough, globus, sore throat, dysphonia, and/or throat clearing of ≥8 weeks duration, 24 h pH-impedance monitoring (pH-IM), and without objective evidence of GERD (defined as acid exposure time >6%) were included in the study. The COuGH RefluX score tool was applied and stratified as low probability with ≤2.5 points, intermediate probability with 3.0 to 4.5 points, and high probability with ≥5.0 points. The kappa test assessed the concordance between both tests; the area under the curve (AUR), sensitivity (S), specificity (E), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each result. Results: 164 patients were included; the prevalence of GERD by pH-IM was 32% vs. 40.3% by COuGH RefluX score, the agreement was weak (κ = 0.34; p < 0.001), but the AUR was good (0.720 ± 0.17; p < 0.001). A score ≤ 2.5 had S = 49%, E = 88%, PPV = 89%, and NPV = 42% to rule out proven GERD, while a score ≥ 5 had S = 65%, E = 71%, PPV = 52%, and NPV = 82% for proven GERD. Conclusions: The COuGH RefluX score has low sensitivity but adequate specificity for GERD diagnosis in Mexican patients with chronic laryngopharyngeal symptoms.

Validation of the Japanese version of the Esophageal Hypervigilance and Anxiety Scale for esophageal symptoms

BACKGROUND

The Esophageal Hypervigilance and Anxiety Scale (EHAS) is an English questionnaire created in the USA to assess these factors in all patients with esophageal diseases. The aim of this study was to develop and validate the Japanese version of EHAS and investigate the relationship between EHAS scores and symptoms in untreated disorders of esophagogastric junction (EGJ) outflow.

METHODS

This prospective study recruited patients who underwent high-resolution manometry (HRM) at six tertiary centers in Japan. The EHAS was translated to Japanese using standard forward and backward translation methods. Patients completed the following questionnaires: the Japanese EHAS, Eckardt score, Gastroesophageal Reflux Disease Questionnaire, and Hospital Anxiety and Depression Scale for assessment of construct validity. Logistic regression analysis identified factors associated with esophageal symptom severity in untreated disorders of EGJ outflow.

RESULTS

Overall, we analyzed 432 patients. Their main symptoms were dysphagia and reflux. The most common HRM diagnosis was normal (35.9%), followed by achalasia (29.4%). The Japanese EHAS demonstrated excellent reliability, and construct validity, with two subscales similar to the original EHAS. Total EHAS score moderately correlated to Eckardt score (r = 0.545, p < 0.001). In 113 patients with untreated disorders of EGJ outflow, multivariable analysis demonstrated that younger age, type II achalasia, and higher EHAS score were independently associated with higher Eckardt score.

CONCLUSIONS

The Japanese EHAS is a reliable and valid questionnaire. Its subscale scores can be used as in the original version with some caution. Future studies are warranted to assess the appropriateness of factor loading.

Long-term outcomes of pneumatic balloon dilation versus peroral endoscopic myotomy in type I and II achalasia patients: a propensity score-matched analysis

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) shows higher efficacy than pneumatic balloon dilation (PBD) for type I and II achalasia over 2 years. However, long-term durability beyond 5 years remains under-investigated. This study assessed the long-term efficacy of PBD versus POEM.

METHODS

This retrospective comparative study examined treatment-naïve achalasia patients who underwent either PBD or POEM. Cohort balance was achieved through propensity score (PS) matching based on age, sex, Eckardt score, and Charlson Comorbidity Index. The primary outcome was the time to a second intervention. Secondary outcomes were treatment failure, Eckardt score, number of intervention sessions, weight gain, and adverse events.

RESULTS

Of the 127 patients, 67 underwent PBD and 60 underwent POEM, with an average follow-up of 7 years (interquartile range, 5-10). After PS matching, 100 patients with 1:1 matching were included in the analysis. Baseline characteristics, including clinical, endoscopic, and manometric attributes, were comparable between groups. The POEM group had a significantly longer time to a second intervention than the PBD group (hazard ratio, .139; 95% confidence interval, .048-.405) and underwent less endoscopic sessions (P < .001 by linear marginal model analysis) within the first 2 years. Beyond 2 years, subsequent interventions were comparable between groups. There were no differences in the Eckardt score or weight gain. Hospital stays were shorter in the PBD group (2 vs 4 days, P < .001). POEM patients had more adverse events, including perforation.

CONCLUSIONS

POEM demonstrated greater long-term durability than PBD, but PBD was associated with shorter hospital stays and fewer adverse events.

Functional constipation is associated with long-term clinical failure after gastric per-oral endoscopic myotomy for the treatment of gastroparesis

BACKGROUND

This study investigates the role of functional constipation (FC) in predicting the long-term success of Gastric Per-oral Endoscopic Myotomy (G-POEM) for treating gastroparesis.

METHODS

This was a retrospective observational study. Patients who underwent G-POEM between July 2015 and August 2022 with > 6-month follow-up were included. The primary objective was to evaluate the relationship between FC and G-POEM success. Secondary objectives included documenting the role of other digestive motility disorders, history of eating disorders, chronic opioid use, and cannabis use. Multivariate logistic regression analysis was used to evaluate the relationship between clinical success and various parameters, including FC.

RESULTS

80 patients were included, 58 women (72.5%) and 22 men (27.5%) with a mean age of 51.78 years. The mean follow-up was 3.4 years. Clinical success was observed in 52.5% of the patients' post-G-POEM. 42.5% had FC, 17.7% had esophageal motility disorders (EMD), and 13.9% had other motility disorders. In univariate analysis, FC and EMD were more frequent in patients with failure: 57.89 vs 28.57%, p = 0.015 and 28.95 vs 7.32%, p = 0.017, respectively. In multivariate analysis, the presence of FC (OR = 0.281 [0.105; 0.75], p = 0.0113) was the only predictive factor for success.

CONCLUSION

FC emerged as a significant predictor of lower clinical success rates after G-POEM. It suggests that an expanded gastrointestinal evaluation and treatment of other motility disorders may improve the outcomes for patients with gastroparesis treated with G-POEM.

Esophageal motility disorders other than achalasia

Esophageal motility disorders can have a major impact on quality of life. Dysphagia is the most commonly reported symptom; however, patients with esophageal dysmotility can also present with other symptoms such as chest pain and tightness, food impaction, regurgitation and heartburn. It is important to be aware of the spectrum of esophageal motility disorders so that timely and accurate diagnosis can be made. The Chicago Classification uses a hierarchical classification system that divides motility disorders as disorders of outflow obstruction and disorders of peristalsis. The disorders of esophago-gastric junction (EGJ) outflow include Type I, II and III achalasia and EGJ outflow obstruction. The disorders of peristalsis include absent contractility, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility. There are several diagnostic tools such as endoscopy, barium esophagram, high resolution manometry, and functional luminal imaging probe that can aid in evaluating esophageal motility disorders. A multidisciplinary approach including a primary care physician, radiologist, gastroenterologist, and surgeon may be beneficial for accurate diagnosis and proper treatment. The purpose of this paper is to discuss the diagnosis and management of esophageal dysmotility disorders other than achalasia.

Clinical characteristics and esophageal motility in patients with gastric cardia submucosal tumors and associated changes after endoscopic resection

BACKGROUND

This study aimed to investigate the clinical characteristics and esophageal motility of patients with gastric cardia submucosal tumors (SMTs) and the associated changes after endoscopic resection based on high-resolution impedance manometry (HRIM).

METHODS

From our electronic database, we identified patients who underwent pre-operative evaluation of gastric cardia SMTs between 2015 and 2023. All patients completed standardized symptom questionnaires and underwent endoscopic ultrasonography and HRIM. Endoscopic resection via submucosal dissection or submucosal tunnel endoscopic resection was performed, followed by esophagogastroduodenoscopy and HRIM three months later. Esophageal motility on HRIM was compared based on the updated Chicago Classification v4.0.

RESULTS

Thirty patients (mean age, 47.4 ± 12.8 years; male, 50%) were analyzed. Most patients were asymptomatic (43.3%), while others presented with epigastralgia, regurgitation, chest pain, or dysphagia. On endoscopic ultrasonography, the average tumor size was 16.7 ± 4.5 mm (range, 10.0-30.0 mm), and most tumors originated from the fourth layer (80%). On HRIM, eight patients (26.7%) had abnormal esophageal motility, including five with ineffective esophageal motility (IEM) and three with esophagogastric junction outflow obstruction. Complete resection was achieved in 25 of the 27 patients (92.6%) who underwent endoscopic treatment. Pathology revealed leiomyomas (96%) and gastrointestinal stromal tumors (4%). No significant differences in symptom profiles or HRIM parameters were observed after tumor resection. Three patients with pre-operative IEM exhibited normal motility at the follow-up HRIM.

CONCLUSION

Up to 26.7% of patients with gastric cardia SMTs had abnormal esophageal motility on HRIM. Endoscopic resection of these SMTs was effective and safe and appeared to improve esophageal motility in patients with IEM.

Reflux Seen on a Barium Swallow is Not a Substitute For Ambulatory Reflux Monitoring in Symptomatic Patients

OBJECTIVE

Gastroesophageal reflux (GER) is often reported in barium studies (GERB). We aimed to evaluate whether GERB associates with parameters defining conclusive reflux using Lyon criteria on esophageal physiological testing (GERpH).

METHODS

Adults who underwent both ambulatory reflux monitoring off antisecretory therapy and barium esophagogram between 2018 and 2023 were eligible for inclusion in this retrospective study. All reflux monitoring studies were independently reviewed to extract acid exposure time (AET) and number of reflux episodes. GERpH was diagnosed based on Lyon consensus criteria, and compared with GERB reported on barium esophagogram. Performance characteristics of GERB in predicting AET >6% and GERpH by Lyon criteria were calculated.

RESULTS

Of 182 patients (median age: 55.0 y, 69.8% females, median body mass index: 29.8 kg/m2), 61 had GERB and 101 had GERpH, whereas 58 had neither GERB nor GERpH. AET >6% was seen in 39.3% with GERB, and never with GERB without GERpH. The sensitivity and specificity of GERB in predicting AET >6% were 31.6% and 65.1%; corresponding values in predicting conclusive gastroesophageal reflux disease were 37.6% and 71.6%, respectively. A hiatus hernia (HH) was seen in 46.8% with GERB and was associated with higher median AET (6.0% vs 3.8% without HH, P = 0.003) and higher frequency of AET >6% (50.6% vs 32.5%, P = 0.032), but not higher reflux episodes (P ≥ 0.51).

CONCLUSIONS

In patients with symptoms suspicious of reflux disease, reflux seen on a barium esophagogram has suboptimal performance characteristics in predicting conclusive gastroesophageal reflux disease. HH identified on barium esophagography is associated with a higher reflux burden on reflux monitoring.

An expert's guide to classical manometric patterns seen in high-resolution colonic manometry

INTRODUCTION

High-resolution colonic manometry is a research and diagnostic tool used to evaluate colonic motility. Used in health it helps us understand normal colonic motility and the colonic response to physiological stimuli such as meal, as well as chemical (laxatives) and mechanical (distension) stimuli. In pediatric and adult patients with suspected colonic disorders, it can help to understand the abnormal colonic motility associated with the condition.

AREA COVERED

High-resolution manometric catheters contain multiple closely spaced sensors that detect intraluminal pressure changes and contractile force, which can be interpreted as contractile activity. This activity forms several distinctive motor patterns that help in understanding normal colonic physiology and provide insights into the potential pathophysiology underlying colonic disorders such as constipation. After a PubMed search of colonic high-resolution manometry studies, this review provides an overview of the characterized motor patterns, when they occur, how they are initiated, their clinical relevance, and their role, if any, in guiding therapeutic interventions.

EXPERT OPINION

High-resolution colonic manometry has identified motor patterns that were missed or mislabeled by low-resolution recordings. How best to use this information to guide treatment remains to be determined.

Diagnostic Accuracy of Timed Barium Esophagram for Achalasia

BACKGROUND AND 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.

Anti-reflux mucosectomy for proton pump inhibitor refractory gastroesophageal reflux disease with hiatal hernia: A case report

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a prevalent chronic condition primarily treated with proton pump inhibitors (PPIs). However, patients with PPI-refractory GERD and hiatal hernia present significant therapeutic challenges, with conventional treatments often yielding unsatisfactory outcomes. While anti-reflux mucosectomy (ARMS) has emerged as a promising treatment, its efficacy in cases with hiatal hernia remains understudied. The primary objective of this case report is to evaluate the safety and efficacy of ARMS in treating PPI-refractory GERD complicated by hiatal hernia.

CASE PRESENTATION

We report the case of a 77-year-old female patient with PPI-refractory GERD and significant hiatal hernia who underwent ARMS. The procedure successfully reconstructed the barrier at the gastroesophageal junction (GEJ), resulting in marked symptom improvement and enhanced quality of life at 3-month follow-up.

CONCLUSIONS

This case demonstrates that ARMS can be an effective therapeutic option for PPI-refractory GERD patients with hiatal hernia, challenging previous contraindications. Further studies with larger patient cohorts are warranted to validate these findings.

Distinct and reproducible esophageal motility patterns in children with esophageal atresia

OBJECTIVES

Esophageal atresia (EA) is a significant congenital anomaly, with most survivors experiencing esophageal dysmotility. Currently, there is no reliable way to predict which patients will develop significant, life-threatening dysmotility. Using high-resolution impedance manometry (HRIM), this study aimed to characterize the common pressure topography patterns in children with repaired EA.

METHODS

This prospective longitudinal cohort study focused on children (<18 years) with repaired EA. Utilizing HRIM, esophageal motility patterns were studied. Repeat manometric assessments were performed in a selected group.

RESULTS

Seventy-five patients with EA (M:F = 43:32, median age 15 months [3 months to 17 years]) completed 133 HRIM studies. The majority (54 out of 75, 85.3%) had EA with distal tracheo-esophageal fistula. Thirty-five out of 75 (46.7%) underwent one study, 24 out of 75 (32.0%) two studies, 14 out of 75 (18.7%) three studies, and 2 out of 75 (2.7%) four studies. Seventy-two patients had analyzable studies. Three common motility patterns were demonstrated: (1) aperistalsis (26 out of 72, 36.1%); (2) distal esophageal contraction (25 out of 72, 34.7%); and (3) pressurization (6 out of 72, 8.3%). A minority demonstrated combination patterns, including aperistalsis with weak distal contraction (10 out of 72, 13.9%) and aperistalsis with pressurization (2 out of 72, 2.8%). Contraction was normal in 3 out of 72 (4.2%). At repeat assessment, the dominant motility pattern persisted in 26 out of 38 (68.4%) of the second studies and 9 out of 15 (60.0%) of the third studies.

CONCLUSION

Utilizing HRIM in children with repaired EA, we have demonstrated objective, distinct, and reproducible motility patterns. In this cohort, the majority of motility patterns were maintained longitudinally, and dysphagia scores remained unchanged, even after dilatation.

Robotic versus laparoscopic heller myotomy for esophageal achalasia: an updated systematic review and meta-analysis

BACKGROUND

The surgical treatment for esophageal achalasia has evolved over the years, with laparoscopic Heller myotomy (LHM) and partial fundoplication becoming widely used worldwide. More recently, an increased interest in the robotic Heller myotomy (RHM) has arisen.

PURPOSE

Compare short-term and functional outcomes of RHM vs. LHM.

METHODS

Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcome was esophageal perforation (EP). Risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (95% CI) were effect size and relative inference measures. PROSPERO Registration Number: CRD42024512644.

RESULTS

Fourteen observational studies (12962 patients) were included. Of those, 2503 (19.3%) underwent RHM. The patient age ranged from 34 to 66 years and 51.7% were males. EP occurred in 259 patients (1.99%). The cumulative incidence of EP was 1.67% for RHM and 2.07% for LHM. Compared to LHM, RHM was associated with a reduced risk of EP (RR: 0.31; 95% CI 0.16-0.59). No differences were found in term of dysphagia requiring reoperation or additional endoscopic procedures (RR: 0.47; 95% CI 0.20-1.09) and postoperative Eckardt score (SMD: -0.42; 95% CI -0.94, 0.11). Blood loss, conversion to open, operative time, and hospital length of stay were comparable.

CONCLUSIONS

RHM may be associated with a reduced risk of EP compared to LHM. However, because of selection bias, diverse surgeon expertise, variations in surgical technique, and prior endoscopic procedures these findings should not be viewed as conclusive while the superiority of one approach over the other remains to be established.

A Standardized Approach to Performing and Interpreting Functional Lumen Imaging Probe Panometry for Esophageal Motility Disorders: The Dallas Consensus

BACKGROUND & AIMS

Functional lumen imaging probe (FLIP) panometry provides assessment of the esophagogastric junction opening and esophageal body contractile activity during an endoscopic procedure and is increasingly being incorporated into comprehensive esophageal motility assessments. The aim of this study was to provide a standardized approach and vocabulary to the procedure and interpretation and update the motility classification scheme.

METHODS

A working group of 19 FLIP panometry experts convened in a modified Delphi consensus process to produce and assess statements on the FLIP panometry procedure and interpretation. Three rounds of voting were conducted on an agreement scale of 1-9 for appropriateness, followed by face-to-face discussions and an opportunity for revisions of statements. The "percent agreement" was the proportion of votes with score ≥7 indicating level of agreement on appropriateness.

RESULTS

A total of 40 statements were selected for final inclusion in the Dallas Consensus, including FLIP panometry protocol, interpretation of esophagogastric junction opening and contractile response, and motility classification scheme. Key statements included: "FLIP panometry should be interpreted in the context of the clinical presentation, the accompanying EGD [esophagogastroduodenoscopy] findings and other relevant complementary testing" (median response 9.0; 100% agreement). "A major motor disorder is unlikely in the setting of a 'normal' FLIP panometry classification" (median response 9.0; 94% agreement). "Diminished or absent contractile response with reduced esophageal opening (ie, nonspastic obstruction) supports the diagnosis of a disorder of EGJ [esophagogastric junction] outflow" (median response 8.5; 94% agreement).

CONCLUSIONS

The standardized approach for performance and interpretation of the Dallas Consensus can facilitate use of FLIP panometry in broad clinical settings.

Mean Nocturnal Baseline Impedance May Be Greater Than 2500 Ohms in Chinese Patients With GERD

BACKGROUND

According to the Lyon Consensus 2.0, mean nocturnal baseline impedance (MNBI) greater than 2500 Ω is considered evidence against gastroesophageal reflux disease (GERD). However, we have observed that a subset of GERD patients presents with MNBI exceeding 2500 Ω.

AIMS

To investigate MNBI characteristics in Chinese GERD patients, identify clinical features of those with normal MNBI, and examine factors influencing MNBI values.

METHODS

We retrospectively investigated 259 patients with typical reflux symptoms. Demographics, symptoms, proton pump inhibitor (PPI) response, esophageal motility parameters were compared between patients with different AET levels and MNBI levels.

RESULTS

Among the cohort, 38.2% had AET 4%-6%, and 37.5% had AET > 6%. Notably, 95.2% of patients with AET < 4%, 49.5% with AET 4%-6%, and 17.6% with AET > 6% had MNBI > 2500 Ω. Independent risk factors for MNBI > 2500 Ω included the number and duration of supine acid reflux and lower esophageal sphincter (LES) resting pressure. In GERD patients with heartburn, patients with MNBI ≤ 2500 Ω had higher PPI response than MNBI > 2500 Ω (81.1% vs. 55.6%, p = 0.009).

CONCLUSIONS

Approximately one-third of Chinese GERD patients have an MNBI > 2500 Ω. The thresholds of MNBI for supporting or ruling out GERD in the Chinese population should be adjusted. MNBI values are independently predicted by the severity of supine acid reflux and the LES resting pressure. GERD patients with mild supine acid reflux may still exhibit normal MNBI levels. Patients with lower MNBI values tend to show better responses to PPI therapy.

Achalasia: Diagnosis and Management

Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Typical symptoms of achalasia are dysphagia, retrosternal chest pain, regurgitation, and weight loss. Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.

Delta-integrated relaxation pressures as a new high-resolution manometry metric to predict the positive outcome of laparoscopic Heller-Dor in patients with achalasia

BACKGROUND

There is no consensus on the definition of failure after treatment in patients with achalasia. The Eckardt score is used to define clinical outcomes. However, objective metrics are lacking. This study aimed to identify whether any high-resolution manometry (HRM) parameters may be useful in predicting a positive outcome after laparoscopic Heller-Dor (LHD).

METHODS

Patients who underwent LHD between 2012 and 2022 were enrolled. The patients were divided according to the outcome: the success group (SG) and the failure group (FG). In addition to the common HRM parameters, we measured the difference between pre- and postoperative integrated relaxation pressures (∆-IRPs). A receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of each HRM parameter.

RESULTS

Of note, 336 patients (92.3%) were classified in the SG, and 28 patients (7.7%) were classified in the FG. No difference was found in terms of manometric types, symptom duration, and history of previous treatments. Preoperative lower esophageal sphincter (LES) pressure and IRP were higher in the SG than in the FG (41 vs 35 mm Hg [P =.03] and 33 vs 26 mm Hg [P =.002], respectively). The postoperative LES metrics were similar between the 2 groups, except for the ∆-IRP that was higher in the SG (23 mm Hg [IQR, 15-31]) than in the FG (14 mm Hg [IQR, 9-17]) (P =.0002). In the univariate analysis, age, LES preoperative pressure, IRP, and ∆-IRP were factors able to predict a positive clinical outcome. In the multivariate analysis, the ∆-IRP was the only parameter independently related to clinical success (odds ratio, 0.94; 5%-95% CI, 0.89-0.99). The ROC curve for the ∆-IRP showed an area under the curve of 0.71, with a threshold value set at 16.5 mm Hg (sensibility of 71% and specificity of 70%).

CONCLUSION

Our data showed that the ∆-IRP with a threshold of 16.5 mm Hg could represent a new objective tool for predicting the long-term positive outcome of LHD in patients with esophageal achalasia.

Exploring esophagogastric junction morphology and contractile integral: implications for refractory gastroesophageal reflux disease pathophysiology

BACKGROUND

Evaluate the clinical significance of esophagogastric junction (EGJ) morphology and esophagogastric junction contractile integral (EGJ-CI) in refractory gastroesophageal reflux disease (RGERD) patients.

METHODS

From June 2021 to June 2023, 144 RGERD patients underwent comprehensive evaluation, recording symptom scores, demographic data. GERD classification (NERD or RE, A-D) was based on endoscopic findings. Reflux was assessed through 24-hour pH-impedance monitoring, and high-resolution esophageal manometry(HREM) measured parameters including EGJ-CI.

RESULTS

HREM revealed EGJ morphologies (type I, II, III) in 80.6%, 13.9%, and 5.6% of subjects, respectively. As the separation between the lower esophageal sphincter(LES) and crural diaphragm(CD) increased, EGJ-CI decreased (p < 0.005). Subjects with EGJ morphology types II and III had significantly higher acid exposure times(AET), DeMeester scores, and impedance reflux times than type I (p < 0.05). There was no statistical difference between types II and III. Impedance reflux times in subjects with type III morphology were significantly higher than those with types I and II (p < 0.05). The optimal EGJ-CI cutoff for distinguishing pathological reflux was 24.8 mmHg·cm, with 68% sensitivity, 72.3% specificity, and an AUC of 0.693 (95% CI 0.609-0.768). Logistic regression analysis identified EGJ-CI <24.8 mmHg·cm (OR = 2.5, 95% CI 1.1-5.5, p = 0.022) and ineffective esophageal motility(IEM) (OR = 2.4, 95% CI 1.2-5.2, p = 0.027) as independent risk factors.

CONCLUSION

EGJ-CI is crucial for clinically assessing EGJ barrier function, predicting pathological reflux and selecting patients with persistent reflux symptoms for surgery.

A Software Framework for the Functional Lumen Imaging Probe-Mechanics (MechView)

BACKGROUND

The functional lumen imaging probe (FLIP) has proven to be a versatile device for diagnosing esophageal motility disorders and estimating esophageal wall compliance, but there is a lack of viable software for quantitative assessment of FLIP measurements.

METHODS

A Python-based web framework was developed for a unified assessment of FLIP measurements including clinical metrics such as esophagogastric junction (EGJ) distensibility index (DI), maximum EGJ opening diameter, mechanics-based metrics for estimating strength, and effectiveness of contractions, such as contraction power and displaced volume, and machine learning-based clustering and predictive algorithms such as the virtual disease landscape (VDL) and EGJ obstruction probability. The clinical and VDL probability metrics were then validated using FLIP data from 121 subjects constituting different categories of EGJ opening which were diagnosed by expert clinicians.

RESULTS

The clinical metrics estimated by the framework matched the manual diagnosis of the clinicians. Misclassifications were minimal and were mostly between neighboring groups, that is, normal and borderline normal or borderline normal and borderline reduced EGJ opening. Similar results were also obtained for the VDL probability metrics. The misclassifications were further analyzed by clinicians and approved.

CONCLUSION

The FLIP web framework was developed and validated to reliably estimate various clinical, mechanical, and machine learning-based metrics for diagnosing esophageal motility disorders.

The Relationship between Upper Esophageal Sphincter Manometry Function and Esophageal Motility Disorders

OBJECTIVE

High-resolution manometry (HRM) provides measures of esophageal function which are used to classify esophageal motility disorders based on the Chicago Classification system. Upper esophageal sphincter (UES) measures are obtained from HRM, but are not included in the classification system, rendering the relationship between UES measures and esophageal motility disorders unclear. Furthermore, changes in the acceptable amount of esophageal dysfunction between versions of this classification system has created controversy. The objective of this study was to determine the relationship between UES measures and esophageal function.

STUDY DESIGN

Cross-sectional study.

SETTING

Referral centre.

METHODS

HRM studies from the Calgary Gut Motility Center were reviewed for UES mean basal pressure, mean residual pressure, relaxation time-to-nadir, relaxation duration, and recovery time. Patients were grouped by number of failed swallows according to different iterations of the Chicago Classification: 0 to 4 (Group 1), 5 to 7 (Group 2), and 8 to 10 (Group 3).

RESULTS

2114 patients (65.1% female, median age 56 y) were included. There were significant increases in UES mean basal pressure (P < .001), mean residual pressure (P < .001), relaxation duration (P < .001), and recovery time (P < .001) between groups. Positive correlations existed between number of failed swallows and UES mean basal pressure (r = 0.143; P < .001), mean residual pressure (r = 0.201; P < .001), relaxation duration (r = 0.145; P < .001), and recovery time (r = 0.168; P < .001).

CONCLUSIONS

Differences in UES measures exist among patients with failed swallows, with a positive correlation between UES dysfunction and increasing dysmotility. Our findings illustrate that UES measures are closely related to esophageal function, and that even minor esophageal dysfunction is related to UES dysfunction.

Laparoscopic transhiatal surgery based on high-resolution manometric evaluation of epiphrenic esophageal diverticulum

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50 mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6 mmHg (> 26 mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6 mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

Short esophageal myotomy versus standard myotomy for treatment of sigmoid-type achalasia: results of an international multicenter study

BACKGROUND AND AIMS

Patients with sigmoid-type achalasia can be challenging to treat with peroral endoscopic myotomy (POEM). A short myotomy improves technical success; however, outcomes have not previously been evaluated.

METHODS

This was a multicenter, international, retrospective study of patients who underwent POEM with short (≤4 cm) or standard esophageal myotomy. Outcomes included clinical and technical success, procedural adverse events, and reflux rates.

RESULTS

A total of 109 patients with sigmoid achalasia (sigmoid, n = 74; advanced sigmoid, n = 35) underwent POEM across 13 centers (short myotomy, n = 59; standard, n = 50). Technical success was 100% across both groups. Patients who underwent short myotomy had a significantly shorter mean procedure time (57.7 ± 27.8 vs 83.1 ± 44.7 minutes, P = .0005). A total of 6 adverse events were recorded in 6 patients (5.5%; 4 mild, 2 moderate); the adverse event rate was not significantly different between short and standard groups. Ninety-eight patients had follow-up data (median, 3.6 months; interquartile range, 1-14 months). Clinical success was 94% (short, 93%; standard, 95%; P = .70) and did not differ based on achalasia subtype or sigmoid achalasia severity. Twenty-one (22%) patients reported post-POEM reflux and 44% (16 of 36) had objective evidence of pathologic reflux. Rates of pathologic reflux were significantly increased in the standard versus short group (odds ratio, 18.0; 95% confidence interval, 2.0-159.0; P = .009).

CONCLUSIONS

POEM with short myotomy is effective and safe for the short-term treatment of sigmoid and advanced sigmoid achalasia. Short myotomy may lead to less reflux than standard myotomy.

Impact of peroral endoscopic myotomy on the endoscopic pressure study integrated system

OBJECTIVES

The endoscopic pressure study integrated system (EPSIS) is an endoscopic diagnostic system utilized for evaluation of lower esophageal sphincter function. Although previous studies have determined that EPSIS was effective as a tool for the diagnosis of achalasia, it remains uncertain if EPSIS can detect significant changes before and after peroral endoscopic myotomy (POEM), which is the premier treatment for achalasia. This study aimed to evaluate the effectiveness of EPSIS as an objective diagnostic tool for assessing the clinical effect of POEM.

METHODS

We conducted a retrospective analysis of patients who underwent POEM from January 2022 to December 2023. The patients underwent EPSIS preoperatively and 2 months postoperatively. Intragastric pressure (IGP) parameters, including the maximum IGP, IGP difference, and waveform gradient were compared pre- and post-POEM. These parameters also were compared between two groups: the postoperative gastroesophageal reflux disease (GERD) group and the non-GERD group.

RESULTS

A total of 50 patients were analyzed. The mean maximum IGP was significantly lower postoperatively than preoperatively (15.0 mmHg vs. 19.8 mmHg, P < 0.001). The mean IGP difference and waveform gradient were also significantly lower postoperatively than preoperatively (8.0 mmHg vs. 12.2 mmHg, P < 0.001; and 0.26 mmHg/s vs. 0.43 mmHg/s, P < 0.001, respectively). The mean postoperative waveform gradient was significantly lower in the GERD group (17 patients, 34%) than in the non-GERD group (33 patients, 66%) (0.207 mmHg vs. 0.291 mmHg, P = 0.034).

CONCLUSION

The results supported the use of EPSIS as an effective diagnostic tool for assessing the effect of POEM.

Comprehensive analysis of nutritional parameters in patients with idiopathic achalasia: A prospective study in India

BACKGROUND AND AIM

Achalasia cardia, a primary motility disorder of the esophagus, poses significant malnutrition risks. This study aims at comprehensively assessing the nutritional status in untreated achalasia patients, contrasting it with functional gastrointestinal disorders (FGIDs) cases and impact of per-oral endoscopic myotomy (POEM) on nutrition at one-year.

METHODS

We conducted a prospective study, including consecutive achalasia cases, from December 2021 to April 2022 at a tertiary care centre. Biochemical parameters, anthropometry, subjective global assessment (SGA) and malnutrition universal screening tool were used for nutritional assessment. Cases diagnosed with FGIDs served as controls.

RESULTS

As many as 118 cases (41.2 ± 13.9 years, 61% males) with achalasia and 200 controls (43.4 ± 11.9 years, 69% males) were included in the study. Sub-types of achalasia included type I (16.9%), II (76.3%) and III (6.8%). Overall, 38.1% and 6.8% cases were moderately and severely malnourished, respectively. As compared to controls, cases with achalasia had lower pre-albumin (19.4 vs. 25.2; p = 0.001), serum calcium (p = 0.012), vitamin D (p = 0.001), serum iron (p = 0.001), triceps fold thickness (p = 0.002) and hand-grip strength (p = 0.001). On univariate analysis, type-I achalasia, body mass index, % weight loss, lower esophageal sphincter pressures and Eckardt scores were predictors of malnourishment (SGA). On multivariate analysis, type of achalasia, mid arm circumference and low body mass index were significant predictors of malnourishment in cases with achalasia. There was significant improvement in the nutritional status after POEM at one-year follow-up.

CONCLUSION

Achalasia patients demonstrate a notably higher risk of malnutrition compared to individuals with FGIDs. Nutritional status significantly improves after POEM. (NCT05161923).