Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia—Anatomy Matters!

Abstract

INTRODUCTION: To compare the utility of the distensibility index (DI) on functional lumen imaging probe (FLIP) topography to other esophagogastric junction (EGJ) metrics in assessing treatment response in achalasia in the context of esophageal anatomy. METHODS: We prospectively evaluated 79 patients (at ages 17–81 years; 47% female patients) with achalasia during follow-up after pneumatic dilation, Heller myotomy, or per-oral endoscopic myotomy with timed barium esophagram, high-resolution impedance manometry, and FLIP. Anatomic deformities were identified based on consensus expert opinion. Patients were classified based on anatomy and EGJ opening to determine the association with radiographic outcome and Eckardt score (ES). RESULTS: Twenty-seven patients (34.1%) had an anatomic deformity—10 pseudodiverticula at myotomy, 7 epiphrenic diverticula, 5 sigmoid, and 5 sinktrap. A 5-minute column area of >5 cm2 was best associated with an ES of >3, with a sensitivity of 84% (P = 0.0013). Area under the curve for EGJ metrics in association with retention was as follows: DI, 0.90; maximal EGJ diameter, 0.76; integrated relaxation pressure, 0.64; and basal esophagogastric junction pressure, 0.53. Only FLIP metrics were associated with retention given normal anatomy (DI 2.4 vs 5.2 mm2/mm Hg and maximal EGJ diameter 13.1 vs 16.6 mm in patients with and without retention, respectively; P values < 0.0001 and 0.002). Using a DI cutoff of <2.8 as abnormal, 40 of 45 patients with retention (P = 0.0001) and 23 of 25 patients with an ES of >3 (P = 0.02) had a low DI and/or anatomic deformity. With normal anatomy, 21 of 22 patients with retention had a low or borderline low DI. DISCUSSION: The FLIP DI is most useful metric for assessing the effect of achalasia treatment on EGJ opening. However, abnormal anatomy is an important mediator of outcome and treatment success will be modulated by anatomic defects that impede bolus emptying.

The functional lumen imaging probe in gastrointestinal disorders: the past, present, and future

“…DI, as measured by FLIP, was found to be the single most useful metric for assessing the effect of achalasia treatment on EGJ opening. 20 Other centers have reported the benefit of FLIP in tailoring pneumatic dilation, per-oral endoscopic myotomy, and/or Heller myotomy. [21][22][23][24][25][26][27][28] Dysphagia While achalasia is the quintessential esophageal motility disorder, it is relatively rare with an incidence often quoted at 1 per 100,000.…”

Impedance in the evaluation of the esophagus

“…126 A recent study showed that the FLIP EGJ-DI was the most useful assessment metric for evaluating therapeutic response in patients with achalasia when timed barium esophagram, HRIM, and FLIP were compared. 127 In addition, an appropriate intraoperative EGJ CSA during POEM has been proposed. 122 The CSA during POEM evaluated by FLIP correlated with postprocedure reflux as well as clinical response.…”

Esophageal physiology—an overview of esophageal disorders from a pathophysiological point of view

“…34 Long-term achalasia can also lead to anatomic considerations that may significantly impact clinical decision making and outcomes. 35 Symptoms of achalasia classically consist of dysphagia, to solids and liquids, and regurgitation. Chest pain, weight loss, and heartburn can be seen to a variable degree but are less common.…”