Achalasia subtypes can be identified with functional luminal imaging probe (FLIP) panometry using a supervised machine learning process

Abstract

Background: Achalasia subtypes on high-resolution manometry (HRM) prognosticate treatment response and help direct management plan. We aimed to utilize parameters of distension-induced contractility and pressurization on functional luminal imaging probe (FLIP) panometry and machine learning to predict HRM achalasia subtypes. Methods: One hundred eighty adult patients with treatment-naïve achalasia defined by HRM per Chicago Classification (40 type I, 99 type II, 41 type III achalasia) who underwent FLIP panometry were included: 140 patients were used as the training cohort and 40 patients as the test cohort. FLIP panometry studies performed with 16-cm FLIP assemblies were retrospectively analyzed to assess distensive pressure and distension-induced esophageal contractility. Correlation analysis, single tree, and random forest were adopted to develop classification trees to identify achalasia subtypes.

Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry

“…A SOC was defined as a non‐propagating, occluding contraction of the esophageal body that persisted for >10 seconds, occurred in continuity with the EGJ, and was associated with a pressure increase >35 mmHg (Figure 2). 10,15 As both sLESC and SOC appear to represent abnormal contractile responses to LES distension, parameters of EGJ opening (ie, EGJ‐DI and max EGJ diameter) were not applied in these cases which were instead considered independently abnormal.…”

“…Normal contractile response (NCR; defined by RAC Ro6s) and borderline diminished contractile response (BDCR) both included distinct antegrade contractions and were patterns observed among asymptomatic volunteers 9,10 . Contractile response patterns not observed among asymptomatic volunteers, and thus considered “abnormal,” included impaired disordered contractile response (IDCR), absent contractile response (ACR), or spastic‐reactive contractile response (SRCR; which shared features with findings observed in spastic achalasia); Figure 2; Table 1 10,15 . FLIP Panometry studies were collectively reviewed by 4 physicians (AJB, END, JEP, and DAC), and the FLIP pattern was determined by consensus agreement among the reviewers.…”

“…A repetitive retrograde contractions (RRCs) pattern was defined when retrograde contractions of ≥6 axial length occurred at a rate of >9 contractions per minute. SOCs were defined as above 10,15 …”

EndoFLIP: una nueva tecnología

“…Al igual que la MAR, estas contracciones han logrado tipificar la acalasia en 3 tipos, lo cual es bien conocido que tiene valor pronóstico postratamiento (17,18,20). Los patrones de contracciones esofágicas visualizadas por EndoFLIP tienen una sensibilidad/especificidad de 45 %/95 % para el diagnóstico de acalasia tipo 1, 72 %/73 % para el tipo 2 y 93 %/82 % para el tipo 3 (23,24); por lo cual es útil en pacientes cuya MAR no cumple con todos los criterios de Chicago versión 4.0, debido a una peristalsis alterada, pero una presión de relajación integrada (IRP) normal, que con los retos deglutorios y el esofagograma igualmente no logran confirmar la presencia de acalasia (25)(26)(27).…”

Intraoperative Impedance Planimetry (ENDOFLIP)

“…EndoFLIP has been shown to differentiate different achalasia subtypes, such as spastic versus nonspastic achalasia with high accuracy, in comparison to HRM. 19 Surgical management of achalasia includes LHM or peroral endoscopic myotomy (POEM). The goal is to improve bolus transport through the EGJ and prevent esophageal deterioration.…”