Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes

Abstract

High-resolution manometry (HRM), along with the analysis algorithms characterized in the Chicago Classification (CC) first proposed in 2008, have led to a major restructuring of the classification of oesophageal motility disorders. The inherently quantitative output of HRM devices fuelled enthusiastic expectation among motility experts that these advances would add a level of precision to the diagnosis of oesophageal motility disorders that was not previously possible. Nowhere was this advance more evident than in our concept of achalasia, now differentiated into subtypes as a direct result of HRM. Coincident with the assimilation of HRM into clinical practice was the development of a major therapeutic intervention for the management of oesophageal motility disorders, per-oral endoscopic myotomy (POEM). Not only does the POEM procedure provide a therapeutic option for myotomy with reduced morbidity relative to laparoscopic or open myotomy, but it also enables a calibrated intervention that is customized to patient-specific physiology. Together, these develop ments fostered an increasing emphasis on targeting therapy to specific aspects of oesophageal dysfunction, as measured by physiological testing, rather than discrete diagnoses. Again, nowhere is this evolution more evident than in our strategies for managing achalasia. This Consensus Statement examines the effect of HRM on our current understanding of oesophageal motility disorders with a focus on how this technology has affected the diagnosis, epidemiology and management of achalasia and achalasia-like syndromes. on behalf of the International Working Group for Disorders of Gastrointestinal Motility and FunctionAbstract | High-resolution manometry (HRM) and new analysis algorithms, summarized in the Chicago Classification, have led to a restructured classification of oesophageal motility disorders. This advance has led to increased detection of clinically relevant disorders, in particular achalasia. It has become apparent that the cardinal feature of achalasia -impaired lower oesophageal sphincter (LES) relaxation -can occur in several disease phenotypes: without peristalsis (type I), with pan-oesophageal pressurization (type II), with premature (spastic) distal oesophageal contractions (type III), or with preserved peristalsis (outlet obstruction). Furthermore, no manometric pattern is perfectly sensitive or specific for achalasia caused by a myenteric plexopathy, and there is no biomarker for this pathology. Consequently, physiological testing reveals other syndromes not meeting achalasia criteria that also benefit from therapies formerly reserved for achalasia. These findings have become particularly relevant with the development of a minimally invasive technique for performing a long oesophageal myotomy, the per-oral endoscopic myotomy (POEM). Optimal management is to render treatment in a phenotype-specific manner; that is, POEM calibrated to patient-specific physiology for spastic achalasia and the spastic disorders, and more conservative strategies...

Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia‐like syndrome in dogs

“…A recent study indicated improved clinical signs in puppies with congenital ME treated with sildenafil (without documentation of functional LES‐obstruction), perhaps supporting the role of increased LES tone in the pathogenesis of ME in dogs . In people, treatment is dictated largely by clinical variables, patient risk factors, and LES achalasia subclassification . Subclassifications for LES achalasia in people are based on HRM, and treatment responses have been shown to vary based on achalasia subtype .…”

“…In people, treatment is dictated largely by clinical variables, patient risk factors, and LES achalasia subclassification . Subclassifications for LES achalasia in people are based on HRM, and treatment responses have been shown to vary based on achalasia subtype . Although subtypes have been identified in dogs with LES‐AS based on fluoroscopy, numbers of affected animals are insufficient to attempt treatment based on subclassification.…”

Advances in Management of Esophageal Motility Disorders

“…The hallmark disease with EGJ outflow obstruction is achalasia, defined by the combination of impaired lower esophageal sphincter (LES) relaxation and absent peristalsis. However, it has since become clear that obstructive physiology occurs in several syndromes besides classic achalasia [7]. In fact, obstructive physiology can be a function of the EGJ, the distal esophagus, or both.…”

“…Easy cases will always be easy, but no matter what your degree of sophistication, there will always be cases in which clinical judgment ends up the final arbiter. For a detailed discussion of many of the technical challenges of HRM interpretation, the reader is referred to a recent expert consensus on the topic [7]. Pertinent to this discussion, suffice it to say that as much as HRM has advanced the science of motility testing, it has also exposed several fundamental limitations.…”

Assessing Esophageal Function in Achalasia: The Old and the New

“…Nowhere is this evolution more evident than in our concept of achalasia, now diff erentiated into three subtypes and proving to be substantially more prevalent than previously recognized ( 2,3 ). In fact, many disorders previously rendered to alternative diagnoses, or deemed to be "non-specifi c, " are also now recognized to be either achalasia subtypes or cases of incompletely expressed achalasia ( 4 ). In parallel with the global adoption of the CC, the functional luminal imaging probe (FLIP) has emerged as a novel technology capable of quantifying the distensibility of the esophagogastric junction (EGJ), and reduced EGJ distensibility has proven to be a key abnormality in achalasia.…”