Fraukje A. Ponds

Esophagogastric junction distensibility identifies achalasia subgroup with manometrically normal esophagogastric junction relaxation.

Manometric criteria to diagnose achalasia are absent peristalsis and incomplete relaxation of the esophagogastric junction (EGJ), determined by an integrated relaxation pressure (IRP) >15 mm Hg. However, EGJ relaxation seems normal in a subgroup of patients with typical symptoms of achalasia, no endoscopic abnormalities, stasis on timed barium esophagogram (TBE), and absent peristalsis on high‐resolution manometry (HRM). The aim of our study was to further characterize these patients by measuring EGJ distensibility and assessing the effect of achalasia treatment.

Evaluation of Esophageal Motility Utilizing the Functional Lumen Imaging Probe

Objectives:Esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis can be assessed with the functional lumen imaging probe (FLIP) during a sedated upper endoscopy. We aimed to describe esophageal motility assessment using FLIP topography in patients presenting with dysphagia.Methods:In all, 145 patients (aged 18–85 years, 54% female) with dysphagia that completed upper endoscopy with a 16-cm FLIP assembly and high-resolution manometry (HRM) were included. HRM was analyzed according to the Chicago Classification of esophageal motility disorders; major esophageal motility disorders were considered “abnormal”. FLIP studies were analyzed using a customized program to calculate the EGJ-distensibility index (DI) and generate FLIP topography plots to identify esophageal contractility patterns. FLIP topography was considered “abnormal” if EGJ-DI was <2.8 mm2/mm Hg or contractility pattern demonstrated absent contractility or repetitive, retrograde contractions.Results:HRM was abnormal in 111 (77%) patients: 70 achalasia (19 type I, 39 type II, and 12 type III), 38 EGJ outflow obstruction, and three jackhammer esophagus. FLIP topography was abnormal in 106 (95%) of these patients, including all 70 achalasia patients. HRM was “normal” in 34 (23%) patients: five ineffective esophageal motility and 29 normal motility. In all, 17 (50%) had abnormal FLIP topography including 13 (37%) with abnormal EGJ-DI.Conclusions:FLIP topography provides a well-tolerated method for esophageal motility assessment (especially to identify achalasia) at the time of upper endoscopy. FLIP topography findings that are discordant with HRM may indicate otherwise undetected abnormalities of esophageal function, thus FLIP provides an alternative and complementary method to HRM for evaluation of non-obstructive dysphagia.

Distal esophageal spasm and the Chicago classification: is timing everything?

According to the Chicago classification of esophageal motility disorders, distal esophageal spasm (DES) is defined as premature esophageal contractions (distal latency [DL] <4.5 s) for ≥20% of swallows, in the presence of a normal mean integral relaxation pressure (IRP). However, some patients with symptoms of DES have rapid contractions with a normal DL. The aim of this study was to characterize these patients and compare their clinical characteristics to those of patients classified as DES.

Diagnostic features of malignancy-associated pseudoachalasia

Pseudoachalasia is a condition in which clinical and manometric signs of achalasia are mimicked by another abnormality, most often a malignancy.

Incidence and costs of achalasia in The Netherlands

Recent reports show increasing incidence of achalasia in some populations. The aim of this study was to estimate incidence, prevalence, and healthcare costs of achalasia in a large cohort in The Netherlands.

Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm

Abstract Objective: Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Treatment options are limited and often poorly effective. Peroral endoscopic myotomy (POEM) seems an effective and attractive new treatment option for DES. In this case report we describe some of the difficulties that could arise. Materials and methods: A 84-year old man with therapy-refractory DES and complaints of severe dysphagia and chest pain underwent a POEM procedure under general anesthesia. A longer myotomy was performed to cleave the circular muscle layer from start till end of the spastic contractions. Results: The length of the myotomy was 16 cm. Hyperactive spastic contractions during the procedure complicated the creation of the submucosal tunnel, extended the duration (134 vs. 60–90 min for achalasia), increased postoperative pain and prolonged hospital admission. Intravenously nitroglycerin peroperative diminished spastic contractions. Postoperative a remnant of spastic contractions was present, proximal to the myotomy, causing persistent symptoms. Conclusion: Performing POEM for DES is challenging due to reactive hyperactive spastic contractions during the procedure causing technical difficulties and an extended procedure. A long myotomy, several centimeters above the proximal border of the spastic region, is essential to prevent remnants of spasticity.

Single clips versus multi-firing clip device for closure of mucosal incisions after peroral endoscopic myotomy (POEM)

Background and aims: After Peroral Endoscopic Myotomy (POEM), the mucosal incision is closed with endoscopically applied clips. After each clip placement, a subsequent clipping device has to be introduced through the working channel. With the Clipmaster3, three consecutive clips can be placed without reloading which could reduce closure time. We performed a prospective study evaluating efficacy, safety, and ease of use. Closure using Clipmaster3 was compared to closure with standard clips. Methods: Patients undergoing closure with the Clipmaster3 were compared to patients who underwent POEM with standard clip closure. Results: In total, 12 consecutive POEM closures with Clipmaster3 were compared to 24 standard POEM procedures. The Clipmaster3 and the standard group did not differ in sex distribution, age (42 years [29 – 49] vs 41 years [34 – 54] P = 0.379), achalasia subtype, disease duration, length of the mucosal incision (25.0 mm [20 – 30] vs 20.0 mm [20 – 30], P = 1.0), and closure time (622 seconds [438 – 909] vs 599 seconds [488 – 664] P = 0.72). Endoscopically successful closure could be performed in all patients. The proportion of all clips used that were either displaced or discarded was larger for Clipmaster3 (8.8 %) compared to standard closure (2.0 %, P  = 0.00782). Ease of handling VAS (visual analogue scale) score for Clipmaster3 did not differ between endoscopist and endoscopy nurse (7 out of 10). Conclusions: Clipmaster3 is feasible and safe for closure of mucosal incisions after POEM. Clipmaster3 was not associated with reduced closure time. Compared to standard closure, more Clipmaster3 clips were displaced or discarded to achieve successful closure. A training effect cannot be excluded as a cause of these results. Study registration: NCT01405417

Tu1197 A Subgroup of Achalasia Patients With Manometrically Normal LES Relaxation Can Be Identified by Measurements of Esophagogastric Junction Distensibility

Background: Esophageal manometry is the gold standard for diagnosing achalasia. Typical findings are absent peristalsis and incomplete relaxation of the LES (integrated relaxation pressure (IRP) .15 mmHg). However, in a subgroup of patients with typical symptoms of achalasia, stasis on barium esophagogram and absent peristalsis onmanometry, LES relaxation is not impaired. The aim of our study was to further characterize these patients using distensibility measurements of the esophagogastric junction (EGJ) and to study the effect of treatment. Methods: Consecutive patients with typical symptoms of achalasia, no abnormalities on upper endoscopy, significant stasis on barium esophagogram, absent peristalsis but normal IRP were included. Distensibility of the EGJ was measured using impedance planimetry (EndoFLIP). Distensibility was defined as the minimal cross-sectional area (CSA) of the EGJ divided by balloon pressure at volumes of 20, 30, 40 and 50 ml (mm2/mmHg) and was compared to previously established data of 15 healthy controls. The cut-off for normality was determined at the lower 90th percentile of the EGJ distensibility at 50 ml in these controls. Symptom severity was assessed using the Eckardt score, a score ,4 was considered as treatment success. Measurements of EGJ distensibility and Eckardt score were repeated .3 months after treatment. Results: We included 9 patients (5 male; age 21-59 years) with typical symptoms of achalasia, Eckardt score 6 (5-7) (median (IQR)). On esophageal manometry failed contractions were observed in 5 patients, panesophageal pressurization in 3 patients and spastic contractions in 1 patient. The median IRP was 9.3 mmHg (3.712), baseline LES pressure was 8.6 mmHg (4.5-11.9). Distensibility of the EGJ was significantly reduced in patients compared to controls at all balloon volumes: 20 ml (1.97 ± 0.16 vs 2.46 ± 0.54 mm2/mmHg, P ,.05 (mean ± SEM)), 30 ml (1.81 ± 0.08 vs 2.67 ± 0.36 mm2/mmHg, P ,.0001), 40 ml (1.08 ± 0.12 vs 5.02 ± 0.58 mm2/mmHg, P ,.0001) and 50 ml (1.08 ± 0.11 vs 6.28 ± 0.65 mm2/mmHg, P ,.0001). All patients exhibited EGJ distensibility below the cut-off value set for normality (2.9 mm2/mmHg). Treatment was performed in 6 patients (4 pneumodilation, 2 Heller myotomy). Post-treatment, in all of these patients symptomatic improvement was seen (Eckardt 2 (1-2)) and a substantial increase in EGJ distensibility, to a value within the normal range (5.32 ± 0.9 mm2/mmHg) was observed. Conclusions: A subgroup of patients with typical symptoms of achalasia, significant esophageal stasis, absent peristalsis but no impaired LES relaxation on esophageal manometry can have impaired EGJ distensibility at impedance planimetry. These patients can be regarded as having achalasia and respond favorably to achalasia treatment.

Screening for dysplasia with Lugol chromoendoscopy in longstanding idiopathic achalasia

BACKGROUND: Achalasia patients with longstanding disease are considered to be at risk for developing esophageal cancer. Endoscopic screening is not standardized and detection of dysplastic lesions is difficult, for which Lugol chromoendoscopy could be helpful. Aim was to evaluate the efficacy of screening for esophageal dysplasia and carcinoma in patients with longstanding achalasia using Lugol chromoendoscopy. METHODS: In this cohort study achalasia patients underwent three‐annual screening by Lugol chromoendoscopy between January 2000 and March 2016. Patients with low‐grade dysplasia (LGD) underwent yearly screening, patients with high‐grade dysplasia (HGD) or carcinoma were treated. RESULTS: In total, 230 achalasia patients (144 male, median age 52 years (IQR 43–63) at first endoscopy) were included. Three patients (1.3%, 2 male, age 68 years (range 50–87)) developed esophageal squamous cell carcinoma (ESCC), without LGD at the preceding screening. Incidence rate for ESCC was 63 (95% CI 13–183) per 100 000 persons‐years. LGD was observed in 4 patients (1.7%, 2 male, age 64 years (range 57–73)), without progression to HGD/ESCC during a follow‐up of 9 (IQR 7–14) years. ESCC/LGD was diagnosed 30 (IQR 14–36) years after onset of symptoms and 22 (IQR 4–13) years after diagnosis. Lugol chromoendoscopy tripled the detection rate of suspected lesions (111 lesions white light versus 329 lesions Lugol), but only 8% was histopathological confirmed ESCC or LGD. CONCLUSiON: Achalasia patients with longstanding disease (>20 years) have an increased risk to develop esophageal dysplasia and carcinoma. Endoscopic screening using white light and Lugol chromoendoscopy does not accurately identify precursor lesions for ESCC and therefore cannot be systematically recommended.

Rapid drinking challenge during high-resolution manometry is complementary to timed barium esophagogram for diagnosis and follow-up of achalasia

Esophageal stasis is a hallmark of achalasia. Timed barium esophagogram (TBE) is used to measure stasis but exposes patients to ionizing radiation. It is suggested that esophageal stasis can be objectified on high‐resolution manometry (HRM) as well using a rapid drinking challenge test (RDC). We aimed to assess esophageal stasis in achalasia by a RDC during HRM and compare this to TBE.