Spastic secondary contractile patterns identified by FLIP panometry in symptomatic patients with unremarkable high-resolution manometry

Botulinum toxin injection of the lower esophageal sphincter to identify achalasia-variant esophagogastric junction outflow obstruction

Esophagogastric junction outflow obstruction (EGJOO) can be an achalasia variant caused by neuromuscular dysfunction of the lower esophageal sphincter (LES), or the manometric manifestation of mechanical processes that impair EGJ distensibility. Distinction among these conditions has important implications for treatment, but can be difficult. We hypothesized that response to botulinum toxin (BT) injection of the LES could be a diagnostic test for identifying achalasia-variant EGJOO likely to respond to LES muscle-directed invasive therapy. We reviewed our experience with symptomatic EGJOO patients who had BT injection of the LES. Data collected include demographics, esophageal body manometry findings, esophagram evidence of retention, and symptom response at 1-6 months after BT injection categorized as poor, partial, or good. Clinical response to any subsequent LES-directed invasive treatment (EsoFLIP dilation, pneumatic dilation, Heller myotomy, or POEM) also was recorded. Thirteen symptomatic EGJOO patients were included (mean age 55.9 ± 16.4 years; eight men, five women). Symptom response to BT injection was good in six (46%), partial in three (23%), and poor in three (23%); one was lost to follow-up. All five patients who received invasive treatment after partial or good response to BT had a partial or good response to invasive treatment. The one patient who had invasive treatment after a poor response to BT had a poor response to invasive treatment. These findings suggest that a good response to BT injection of the LES can identify an achalasia-variant form of EGJOO that will respond to LES muscle-directed invasive therapy.

Frequent discrepancies among diagnostic tests for detecting lower esophageal sphincter-related obstruction

BACKGROUND

There are frequent discrepancies among high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and esophagram in identifying lower esophageal sphincter (LES)-related obstruction. We aimed to determine the frequency of those discrepancies and how they influenced clinical treatment/outcomes.

METHODS

We identified patients who had all three tests (HRM, FLIP, and esophagram) and endoscopy performed for evaluation of esophageal symptoms in our Center for Esophageal Diseases. Discrepancies among the tests for the presence of LES obstruction were noted, and the performance of individual tests was compared against a consensus opinion rendered by a panel of esophagologists. Binary logistical regression was performed, and ROC curves were generated for prediction of the consensus clinical diagnosis of LES obstruction.

KEY RESULTS

A total of 126 patients (mean age 57.9 ± 17.0 years; 67% female) met inclusion criteria. All three tests agreed on the presence or absence of LES obstruction in only 72 (57%) patients [no LES obstruction in 57 (45%), LES obstruction in 15 (12%)]. Thirteen patients (10%) had a change in management based on additional findings on FLIP +/- esophagram not seen on HRM with 69% having symptomatic improvement after LES-directed intervention. FLIP was the strongest predictor of a consensus diagnosis of LES obstruction by logistic regression and ROC (OR 23.36, AUC 0.796), followed by HRM (OR 15.41, AUC 0.764).

CONCLUSIONS & INFERENCE

High-resolution manometry, functional lumen imaging probe, and esophagram each have considerable limitations for identifying LES obstruction, and discrepancies among these tests occur frequently. Multimodal testing is often required for adequate evaluation of LES-related obstruction.

Relaxation of the lower esophageal sphincter in response to reduced volume distension during FLIP Panometry

BACKGROUND

The esophageal response to stepwise distension during the functional lumen imaging probe (FLIP) Panometry study often parallels high-resolution manometry (HRM) motility diagnoses. This study aimed to describe the changes in FLIP metrics during FLIP emptying, that is, reduced volume distension.

METHODS

Adult patients who completed FLIP and HRM for esophageal motility evaluation were included. Esophagogastric junction (EGJ) opening parameters were assessed during stepwise FLIP filling to volumes of 60 mL ("filling 60 mL"), then 70 mL, and then back to 60 mL ("emptying 60 mL"). HRM studies were analyzed per Chicago classification version 4.0 (CCv4.0).

KEY RESULTS

Among 265 patients included, HRM/CCv4.0 diagnoses included achalasia in 80 patients (30%), normal motility in 70 (26%), and ineffective esophageal motility (IEM) in 43 (16%). EGJ-distensibility index (DI) and EGJ diameter were greater during emptying 60 mL than filling 60 mL in achalasia, normal motility, and IEM (p values <0.002). If applying the emptying 60 mL EGJ-DI (vs. filling 60 mL EGJ-DI), EGJ opening classification changed from reduced EGJ opening to borderline EGJ opening in 31% of achalasia patients and in 2% of patients with normal motility or IEM. EGJ opening classification was unchanged in 69% achalasia and 96% of normal motility/IEM.

CONCLUSIONS AND INFERENCES

This study suggests that isotonic or auxotonic relaxation of the lower esophageal sphincter occurs with reduced volume distension in patients with achalasia and normal motility. The study also supports the importance of utilizing a standardized FLIP motility study protocol (i.e., controlled, stepwise filling to 50 mL, 60 mL, then 70 mL) to provide reliable and generalizable FLIP metrics to facilitate diagnosis of esophageal motility disorders.

Functional luminal imaging probe in the evaluation of esophago-gastric junction outflow obstruction

PURPOSE OF REVIEW

Esophagogastric junction outflow obstruction (EGJOO) comprises a heterogeneous group of conditions that demonstrate impaired deglutitive relaxation of the esophagogastric junction (EGJ) with intact esophageal peristalsis on high-resolution manometry. Functional luminal imaging probe (FLIP) panometry is a powerful tool that can help to clarify the etiology of this manometric diagnosis. The aim of this review is to summarize the use of FLIP for the evaluation and management of EGJOO.

RECENT FINDINGS

FLIP panometry provides measures of esophageal compliance at the EGJ and information on esophageal body contractile responses to balloon distention that have important implications for the management of patients with EGJOO. After excluding anatomic causes of impaired EGJ distensibility, FLIP panometry is useful in differentiating true lower esophageal sphincter dysfunction from manometric artifact. FLIP panometry has been shown to be useful in determining the need for invasive treatment in patients with EGJOO, and in intraoperative tailoring of myotomy procedures.

SUMMARY

FLIP panometry is easy to perform during endoscopy and provides useful information for characterizing the EGJOO population. FLIP panometry can be used to guide treatment and improve outcomes in the management of patients with EGJOO.