Joel M. Sternbach

The Functional Lumen Imaging Probe Detects Esophageal Contractility Not Observed With Manometry in Patients With Achalasia

BACKGROUND & AIMS The functional lumen imaging probe (FLIP) could improve the characterization of achalasia subtypes by detecting nonocclusive esophageal contractions not observed with standard manometry. We aimed to evaluate esophageal contractions during volumetric distention in patients with achalasia using FLIP topography. METHODS Fifty-one treatment-naive patients with achalasia, defined and subclassified by high-resolution esophageal pressure topography, and 10 asymptomatic individuals (controls) were evaluated with the FLIP during endoscopy. During stepwise distension, simultaneous intrabag pressures and 16 channels of cross-sectional areas were measured; data were exported to software that generated FLIP topography plots. Esophageal contractility was identified by noting periods of reduced luminal diameter. Esophageal contractions were characterized further by propagation direction, repetitiveness, and based on whether they were occluding or nonoccluding. RESULTS Esophageal contractility was detected in all 10 controls: 8 of 10 had repetitive antegrade contractions and 9 of 10 had occluding contractions. Contractility was detected in 27% (4 of 15) of patients with type I achalasia and in 65% (18 of 26, including 9 with occluding contractions) of patients with type II achalasia. Contractility was detected in all 10 patients with type III achalasia; 8 of these patients had a pattern of contractility that was not observed in controls (repetitive retrograde contractions). CONCLUSIONS Esophageal contractility not observed with manometry can be detected in patients with achalasia using FLIP topography. The presence and patterns of contractility detected with FLIP topography may represent variations in pathophysiology, such as mechanisms of panesophageal pressurization in patients with type II achalasia. These findings could have implications for additional subclassification to supplement prediction of the achalasia disease course.

Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate.

Objective: We aimed to report long-term outcomes for patients undergoing per-oral endoscopic myotomy (POEM) after our initial 15-case learning curve. Background: POEM has become an established, natural-orifice surgical approach for treating esophageal motility disorders. To date, published outcomes and comparative-effectiveness studies have included patients from the early POEM experience. Methods: Consecutive patients undergoing POEM after our initial 15 cases, with a minimum of 1-year postoperative follow-up, were included. Treatment success was defined as an Eckardt score ⩽3 without reintervention. Gastroesophageal reflux was defined by abnormal pH-testing or reflux esophagitis >Los Angeles grade A. Results: Between January 2012 and March 2015, 115 patients underwent POEM at a single, high-volume center. Operative time was 101 ± 29 minutes, with 95% (109/115) of patients discharged on postoperative day 1. Clavien-Dindo grade III complications occurred in 2.7%, one of which required diagnostic laparoscopy to rule out Veress needle injury to the gall bladder. The rate of grade I complications was 15.2%. At an average of 2.4 years post-POEM (range 12–52 months), the overall success rate was 92%. Objective evidence of reflux was present in 40% for all patients and 33% for patients with a body mass index <35 kg/m2 and no hiatal hernia. Conclusions: POEM performed by experienced surgeons provided durable symptomatic relief in 94% of patients with nonspastic achalasia and 90% of patients with type 3 achalasia/spastic esophageal motility disorders, with a low rate of complications. The rate of gastroesophageal reflux was comparable with prior studies of both POEM and laparoscopic Heller myotomy.

High-resolution impedance manometry measurement of bolus flow time in achalasia and its correlation with dysphagia

We assessed whether a high‐resolution impedance manometry (HRIM) metric, bolus flow time (BFT) across the esophagogastric junction (EGJ), was abnormal in achalasia patients subtyped by the Chicago Classification and compared BFT to other HRM metrics.

Complications of botulinum toxin injections for treatment of esophageal motility disorders

In achalasia and spastic esophageal motility disorders, botulinum toxin (botox) injection is considered an effective and low-risk procedure for short-term symptom relief. It is mainly offered to medically high-risk patients. However, no analysis of risks of botox injections has been performed. To determine the incidence and risk factors of procedure-related complications after esophageal botox injections, we analyzed the records of all patients undergoing botox injection therapy for esophageal motility disorders at four university hospitals in Europe and North America between 2008 and 2014. Complications were assigned grades according to the Clavien-Dindo classification. In 386 patients, 661 botox treatments were performed. Main indications were achalasia (51%) and distal esophageal spasm (DES) (30%). In total, 52 (7.9%) mild complications (Clavien-Dindo grade I) were reported by 48 patients, the majority consisting of chest pain or heartburn (29 procedures) or epigastric pain (5 procedures). No ulceration, perforation, pneumothorax, or abscess were reported. One patient died after developing acute mediastinitis (Clavien-Dindo grade V) following injections in the body of the esophagus. In univariate logistic regression, younger age was associated with an increased risk of complications (OR 1.43, 95%CI 1.03-1.96). Treatment for DES, injections into the esophageal body, more injections per procedure, more previous treatments and larger amount of injected botulinum toxin were no risk factors for complications. Esophageal botox injection seems particularly appropriate for high-risk patients due to low complication rate. However, it should not be considered completely safe, as it is associated with rare side effects that cannot be predicted.

High-Resolution Impedance Manometry Metrics of the Esophagogastric Junction for the Assessment of Treatment Response in Achalasia

OBJECTIVES:We aimed to evaluate the value of novel high-resolution impedance manometry (HRIM) metrics, bolus flow time (BFT), and esophagogastric junction (EGJ) contractile integral (CI), as well as EGJ pressure (EGJP) and the integrated relaxation pressure (IRP), as indicators of treatment response in achalasia.METHODS:We prospectively evaluated 75 patients (ages 19–81, 32 female) with achalasia during follow-up after pneumatic dilation or myotomy with Eckardt score (ES), timed-barium esophagram (TBE), and HRIM. Receiver-operating characteristic (ROC) curves for good symptomatic outcome (ES≤3) and good radiographic outcome (TBE column height at 5 min<5 cm) were generated for each potential predictor of treatment response (EGJP, IRP, BFT, and EGJ-CI).RESULTS:Follow-up occurred at a median (range) 12 (3–291) months following treatment. A total of 49 patients had good symptomatic outcome and 46 had good radiographic outcome. The area-under-the-curves (AUCs) on the ROC curve for symptomatic outcome were 0.55 (EGJP), 0.62 (IRP), 0.77 (BFT) and 0.56 (EGJ-CI). The AUCs for radiographic outcome were 0.64 (EGJP), 0.48 (IRP), 0.73 (BFT), and 0.65 (EGJ-CI). Optimal cut-points were determined as 11 mm Hg (EGJP), 12 mm Hg (IRP), 0 s (BFT), and 30 mm Hg•cm (EGJ-CI) that provided sensitivities/specificities of 57%/46% (EGJP), 65%/58% (IRP), 78%/77% (BFT), and 53%/62% (EGJ-CI) to predict symptomatic outcome and 57%/66% (EGJP), 57%/41% (IRP), 76%/69% (BFT), and 57%/66% (EGJ-CI) to predict radiographic outcome.CONCLUSIONS:BFT, a novel HRIM metric, provided an improved functional assessment over manometric measures of EGJP, IRP, and EGJ-CI at follow-up after achalasia treatment and may help direct clinical management.

Learning Curve and Initial Outcomes

Per-oral endoscopic myotomy (POEM) represents the prototype for successful natural orifice surgery; an incisionless, endoscopic approach combined with the precision of a surgical myotomy. Since the initial description by Haru Inoue of the procedure in 2008 and publication of his initial results in 2010 (Inoue et al., Endoscopy 42:265–271, 2010), POEM has been adopted at high-volume esophageal centers around the world. The procedure is being performed by both surgical endoscopists and interventional gastroenterologists. This chapter reviews the characteristics and initial experience of early POEM operators and the existing literature regarding learning curves for the procedure. The growing use of the functional lumen imaging probe for intraoperative physiologic measurements is also discussed, specifically focusing on the dual role as both a quality-control indicator and a potential tool to guide new POEM operators during the learning curve.

Esophagogastric junction distensibility measured by a functional lumen imaging probe with incremental gastric myotomy lengths in achalasia

Limited physiologic evidence exists to guide the optimal distal extent of the gastric myotomy in the surgical treatment of achalasia [1]. The functional lumen imaging probe (FLIP) [2] is a novel physiologic tool that uses impedance planimetry to measure esophagogastric junction (EGJ) distensibility [3] (defined as the cross-sectional area at the EGJ over the intra-balloon pressure). Here, the intra-operative use of FLIP is demonstrated during peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM).

Peroral Endoscopic Myotomy (POEM)

A novel procedure, combining the decreased invasiveness of endoscopic access with the reliability of a surgical myotomy, peroral endoscopic myotomy (POEM) represents a potential paradigm shift in the management of idiopathic achalasia and other esophageal motor disorders. Comprehensive preoperative evaluation by a multidisciplinary team of gastroenterologists and surgeons is essential to confirming candidacy for POEM and appropriately counseling patients on expected outcomes, including the lack of long-term outcome data. The key steps of the procedure are detailed, including initial esophagogastroduodenoscopy (EGD), safe access to the submucosal space, creation of a submucosal tunnel extending at least 3 cm onto the gastric cardia, selective myotomy of the inner circular muscle fibers, and closure of the mucosotomy. Infrequently encountered complications, including bleeding and inadvertent mucosotomy, are also discussed.