Fabienne G. Smeets

Esophagogastric junction distensibility in the management of achalasia patients: relation to treatment outcome.

Achalasia is characterized by a functional esophagogastric junction (EGJ) obstruction. The functional luminal imaging probe (EndoFLIP) is a method to assess EGJ distensibility. In a homogeneous group of newly diagnosed achalasia patients treated with pneumatic dilation (PD), we aimed (i) to determine whether the assessment of EGJ distensibility has added value in the management of achalasia patients and (ii) to evaluate whether EGJ distensibility differs between achalasia subtypes.

Does Measurement of Esophagogastric Junction Distensibility by EndoFLIP Predict Therapy-responsiveness to Endoluminal Fundoplication in Patients With Gastroesophageal Reflux Disease?

Background/Aims In patients with gastroesophageal reflux disease (GERD), an increased esophagogastric junction (EGJ) distensibility has been described. Assessment of EGJ distensibility with the endoscopic functional luminal imaging probe (EndoFLIP) technique might identify patients responsive to transoral incisionless fundoplication (TIF), whereas postoperative measurement of EGJ distensibility might provide insight into the antireflux mechanism of TIF. Therefore, we investigated the value of the EndoFLIP technique in GERD patients treated by TIF. Methods Forty-two GERD patients underwent EGJ distensibility measurement before TIF using the EndoFLIP technique. In a subgroup of 25 patients, EndoFLIP measurement was repeated both postoperative and at 6 months follow-up. Treatment outcome was assessed according to esophageal acid exposure time (AET; objective outcome) and symptom scores (clinical outcome) 6 months after TIF. Results Multiple logistic regression analysis showed that preoperative EGJ distensibility (OR, 0.16; 95% CI, 0.03–0.78; P = 0.023) and preoperative AET (OR, 0.62; 95% CI, 0.42–0.90; P = 0.013) were independent predictors for objective treatment outcome but not for clinical outcome after TIF. The best cut-off value for objective outcome was 2.3 mm2/mmHg for preoperative EGJ distensibility and 11% for preoperative AET. EGJ distensibility decreased direct postoperative from 2.0 (1.2–3.3) to 1.4 (1.0–2.2) mm2/mmHg (P = 0.014), but increased to 2.2 (1.5–3.0) at 6 months follow-up (P = 0.925, compared to preoperative). Conclusions Preoperative EGJ distensibility and preoperative AET were independent predictors for objective treatment outcome but not for clinical outcome after TIF. According to our data, the EndoFLIP technique has no added value either in the preoperative diagnostic work-up or in the post-procedure evaluation of endoluminal antireflux therapy.

Dilation in achalasia - is normal distensibility enough: Author's reply

We thank the author for his interest in our manuscript in which we evaluated the association between Esophagogastric Junction Distensibility (EGJ) distensibility and clinical outcome after pneumatic balloon dilation (PD) in newly diagnosed achalasia patients. We agree that intra-procedure assessment of EGJ distensibility with either the EndoFLIP or EsoFLIP could potentially increase the likelihood of a successful outcome in achalasia patients. However, reference values need to be defined before this technique can be applied in routine clinical practice. A recent systematic review demonstrated a large variability in EGJ distensibility, especially for healthy controls. This is presumably due to use of variable EndoFLIP balloons and different distension protocols. Besides the large variability in healthy controls, contrasting results have been described with regard to EGJ distensibility in achalasia patients after treatment. Teitelbaum et al. described that post-treatment EGJ distensibility in the range of 4.5–8.5 mm/ mmHg was associated with optimal symptomatic outcome in patients treated with peroral esophageal myotomy and laparoscopic Heller myotomy. Aside from the wide range of this ‘optimal’ post-treatment EGJ distensibility, it is important to note that the type of achalasia treatment might influence post-treatment EGJ distensibility. We hypothesize that post-treatment EGJ distensibility might be higher after surgical treatment compared to PD, although repeated PD might potentially have an additive effect compared to single PD. Based on current available literature, it is therefore not possible to define a clear target for post-treatment EGJ distensibility in achalasia patients. O’Dea suggests that the target should be a more distensible EGJ instead of an EGJ distensibility in the normal range. Although achalasia was traditionally characterized by (i) insufficient lower esophageal sphincter relaxation and (ii) absent esophageal peristalsis, Pandolfino et al. found evidence for different achalasia subtypes based on manometric criteria. In addition, Carlson et al. detected esophageal contractility in the majority of untreated achalasia patients (i.e., 27% type I, 65% type II, and all type III patients) and studies found evidence for (partial) return of esophageal peristalsis after surgical treatment. In our opinion, it is therefore questionable whether the treatment goal in achalasia patients should be a higher than normal EGJ distensibility as treatment improves both EGJ obstruction and esophageal peristalsis. Although the EndoFLIP has the potential to guide treatment in achalasia patients, additional research is necessary to define adequate intra-procedure and post-treatment targets for EGJ distensibility to improve clinical outcome.

Systematic review: Disease-specific instruments to assess gastrointestinal symptoms in functional dyspepsia

Functional dyspepsia (FD) is a common functional gastrointestinal disorder with incompletely understood pathophysiology and heterogeneous symptom presentation. Assessment of treatment efficacy in FD is a methodological challenge as response to treatment must be assessed primarily by measuring subjective symptoms. Therefore, the use of patient‐reported outcome measures (PROMs) is recommended by regulatory authorities to assess gastrointestinal symptoms in clinical trials for FD. In the last decades, a multitude of outcome measures has been developed. However, currently no PROM has been approved by the regulatory authorities, and no consensus has been reached with regard to the most relevant outcome measure in FD.

Measurement of Esophagogastric Junction Distensibility May Assist in Selecting Patients for Endoluminal Gastroesophageal Reflux Disease Surgery: Author’s Reply

TO THE EDITOR: We thank the author for his interest in our manuscript.1,2 During the transoral incisionless fundoplication (TIF) procedure, a retractor is anchored at the esophagogastric junction (EGJ) after which tension is applied to advance the EGJ caudally.3,4 Therefore, we agree that lengthening of the EGJ is a substantial mode of action of the TIF procedure. In addition, transmural placement of polypropylene fasteners creates an endoluminal fundoplication through permanent serosa-to-serosa or serosa-to-muscularis fusion with tightening of the distal esophagus, which decreases EGJ diameter and distensibility. 5,6 Therefore, we believe that EGJ distensibility can be an important parameter for evaluation of endoluminal gastroesophageal reflux disease (GERD) surgery like the TIF procedure, although we agree that the immediate decrease in EGJ distensibility after the TIF procedure might be the consequence of postoperative edema.7 It is important to note that consensus is lacking with regard to analysis of parameters obtained from EndoFLIP measurements. According to the most widely accepted approach, EGJ distensibility is assessed based on the narrowest cross sectional area and corresponding intra-bag pressure. Standardized methods to evaluate the change in EGJ length with the EndoFLIP technique are still to be defined. Therefore, we anticipate that development of more extensive biomechanical measures will result in more accurate interpretation of EndoFLIP data. In the present study, we used the EndoFLIP technique in the preoperative diagnostic work-up to predict postoperative outcome. Recent studies highlight that the EndoFLIP technique could be used as an intra-operative quality tool during either anti-reflux or achalasia surgery.8,9 Teitelbaum et al10 described that the EndoFLIP technique is able to guide laparoscopic Heller myotomy and peroral esophageal myotomy to obtain an ideal postoperative EGJ distensibility with regard to both postoperative achalasia and reflux symptoms. In addition, Perretta et al8 provided observational data about the change in EGJ distensibility and diameter during different stages of laparoscopic Nissen fundoplication. In the future, the EndoFLIP method could potentially be used during laparoscopic fundoplication to prevent creation of a hypercompetent valve with associated postoperative symptoms (eg, dysphagia or gas bloating).8 It therefore appears that the EndoFLIP technique has considerable potential as an intra-operative tool. On the other hand, currently available methodologies limit its role with regards to the assessment of EGJ distensibility in the preoperative diagnostic work-up or in post-procedure evaluation of patients undergoing endoluminal GERD surgery like TIF. Additional research is necessary to define the role of the EndoFLIP technique for both the preoperative work-up and tool for intraoperative calibration.

971 Does Post-Procedure Esophagogastric Junction (EGJ) Distensibility Predict Treatment Success in Newly Diagnosed Achalasia Patients?

Introduction: Although initial treatment success rates with pneumatic dilation in achalasia are high, recurrences may occur in more than 50% of patients. Identification of patients in need of re-treatment may be difficult as they are accustomed to a certain level of discomfort. LES pressure ≥10mmHg is considered as an indication for additional therapy but several studies reported a significant proportion of patients with persistent symptoms and low or absent LES pressure. We aimed to study whether post-procedure assessment of esophagogastric junction (EGJ) distensibility can predict treatment success in newly diagnosed achalasia patients. Methods: Eighteen newly diagnosed achalasia patients (10 male, mean age 47.9, range 19-75) underwent 2 pneumatic dilations (PD) with 30and 35mm balloons separated by 1 week. Before and after the 30mm dilation, EGJ distensibility was measured using an endoscopic functional luminal imaging probe (EndoFLIP). Using an EndoFLIP probe with an inflatable bag, EGJ distensibility (cross-sectional area of the diaphragmatic hiatus (CSA)/ pressure within bag during distensions; mm2/mmHg) was measured with 20-, 30-, 40and 50ml distensions. After 3 months patients were assessed by esophageal manometry and with validated symptom questionnaires to determine the Eckardt score, with a score ,4 indicating treatment success. Results: Mean post-procedure EGJ distensibility increased at the 20-, 30, 40and 50ml distention volumes (p,0.05) (Table 1). According to the Eckardt score at 3 months after treatment, 14 out of 18 achalasia patients (77.8%) were considered as having treatment success; treatment failures (n=4) underwent an additional PD with the 40mm balloon. Post-procedure EGJ distensibility of successfully treated patients at 40 and 50ml distention volumes were not significantly higher than in treatment failures (40ml: 3.1±0.5 vs. 2.6±1.2, p=0.69; 50ml: 4.7±0.7 vs. 2.8±1.2, p=0.20). At 3 months after treatment, LES pressure of successfully treated patients was lower than in treatment failures (11±1 vs. 36±12, p=0.13) and a good correlation was found between LES pressure and symptom scores (r=0.88, p,0.001). Post-procedure EGJ distensibility at 40 and 50ml distention volumes correlated poorly with symptom scores at 3 months (40ml: r=-0.10, p=0.70; 50ml: r=-0.26, p=0.37) and modestly with LES-pressure (40ml: r=-0.32, p=0.24; 50ml: r=-0.55, p=0.05). Conclusion: Post-procedure Esophagogastric Junction (EGJ) Distensibility of newly diagnosed achalasia patients improves after pneumatic dilation but is not associated with treatment success after 3 months as compared with symptom scores and LES pressure. Mean EGJ distensibility during volume distentions

Tu1809 Preoperative Esophagogastric Junction (EGJ) Distensibility Predicts Treatment Outcome After Endoscopic Fundoplication in GERD Patients

G A A b st ra ct s reduction of proton pump inhibitors (PPI) therapy after the weight loss. MATERIAL AND METHODS: we enrolled a group of 50 overweight and obese patients with typical and atypical GERD symptoms with previous erosive esophagitis endoscopically proven. These patients were evaluated with two validated questionnaires (QOLRAD and VAS) to detect the prevalence of GERD related symptoms and the ongoing PPI therapy. All patients underwent an anthropometric evaluation (BMI, height, weight, abdominal circumference) and received a personalized hypo-caloric diet with 1200-1500Kcal for women and 1500-1800Kcal for men. The hypocaloric diet was considered effective if at least of 10% weight loss was obtained in each patient. The hypocaloric diet was completed within 6 months. The same anthropometric evaluation and questionnaires were performed at the end of treatment. The results were evaluated with a Student paired t-test and considered statistically significant when p value was , 0.05. RESULTS: Male/female ratio was 0.78 (22/28). Mean age was 49.3(±11,8). Mean BMI decreased from 30.3 (sd ±4,1) to 25.7(±3.1) (p,0.05) and the mean weight loss from 82.1(±16.9) to 69.9 (±14,4) after hypocaloric diet (p,0.05). Symptoms perception decreased both with QUOLRAD and VAS scale (p,0.05). In particular, heartburn decreased from 3.68(±1.9) to 0.28(±0.4) in QUOLRAD scale and from 5.7(±1.8) to 0.6(±0.6) in VAS scale (p,0.05). PPI therapy was completely discontinued in 27/50 (54%) patients, was halved in 16/50 (32%) patients. Only 7/50 (14%) continued the same PPI dosage. CONCLUSION:we can conclude that a 10% of weight loss is recommended in all patients with GERD-related symptoms. This weight reduction could be able to reduce not only symptoms perception but also the dose of PPI therapy.

Mo1063 Treatment of GERD Patients With Transoral Incisionless Fundoplication Leads to a Significant Reduction in Reflux Symptoms and Objective Reflux Parameters at Six and 12 Months Follow up

unanticipated adverse events, or untoward sensation due to LES-EST. There were no reports of treatment related dysphagia and the manometric evaluation of swallow was also normal. Conclusion: Long-term follow-up of 6 months showed LES-EST to be safe and effective for treating GERD patients with incomplete response to PPI therapy. Importantly, LES-EST can be optimized to individual patient needs to further improve patient outcomes. All patients had received significant clinical benefit from LES-EST and the trial has been extended with one-year follow-up results available after March 2012.