The timed barium swallow and its relationship to symptoms in achalasia: Analysis of surface area and emptying rate

Abstract

Achalasia is a motility disorder of the esophagus with hallmark features of failed lower esophageal sphincter (LES) relaxation and absence of normal peristalsis in the esophageal body. The former leads to esophageal stasis which is responsible for most of the symptoms in achalasia. All therapies for achalasia aim to disrupt the non-relaxing LES in order to facilitate esophageal emptying. Although achalasia response to therapy is primarily measured subjectively through various symptom scoring systems, objective

Timed barium swallow for assessing long‐term treatment response in patients with achalasia: Absolute cutoff versus percent change – A cross‐sectional analytic study

“…The results from our study are similar to the findings of a recently published study by Sanagapalli et al assessing the role of esophageal emptying in the cohort of 24 patients with achalasia post‐treatment following either PD (n = 14) or POEM (n = 10) 14 . A 38% decrease in 5‐min barium height post‐therapy from baseline showed 100% sensitivity and 65% specificity in identifying symptomatic improvement post‐treatment 14 . On the other hand, the absolute cutoff value of 5 cm on post‐treatment TBS had 75% sensitivity and 45% specificity for predicting symptomatic improvement 14 .…”

“…A 38% decrease in 5‐min barium height post‐therapy from baseline showed 100% sensitivity and 65% specificity in identifying symptomatic improvement post‐treatment 14 . On the other hand, the absolute cutoff value of 5 cm on post‐treatment TBS had 75% sensitivity and 45% specificity for predicting symptomatic improvement 14 . These findings are similar to our study results showing that percent change is a better indicator of improvement post‐treatment than an absolute cutoff.…”

“…Interestingly, the results from our ROC analysis also showed that a 37% decrease in the pre‐ and post‐treatment barium height at 5 minutes had 91% accuracy in predicting symptomatic response. It should be noted, however, that the study by Sanagapalli et al is limited by small sample size (n = 24) 14 . Nevertheless, these findings from both studies would inform the design and conduct of future studies.…”

Advances and caveats in modern achalasia management

“…Nonetheless, many questions remain unanswered and current trials are often heterogeneous in terms of patient selection (achalasia subtypes, age, preoperative esophageal anatomy, exposure to previous therapy) and treatment protocols. Furthermore, most published trials define treatment outcomes based on the 65 showing that the height of the residual barium column after pneumatic dilatation can worsen due to change in the morphology of the esophagus following achalasia therapy (A), whilst the measurement of the surface area more accurately reflects the reduction of the barium retention following therapy (B) (Figure 2 of Ponds et al 66 -requested permission).…”

“…Although there is often good correlation between emptying on TBS and symptom response, it has been observed that measurement of the height of the barium column at 5 min might not accurately reflect improvement in esophageal emptying nor correlate with symptomatic response with a discordance of up to 31–50%. 63 , 64 A recent study by our group found that, regardless of treatment modality, a change in barium surface area compared with prior to therapy better correlates with treatment response than the conventional post-therapy barium column height at 5 min; out of 24 patients who had achalasia therapy, the percent change in surface area between pre- and post-therapy was best at discriminating between responders and non-responders (sensitivity 100%, specificity 80%) compared with the stand alone standard 5 min post-barium column (sensitivity 75%, specificity 45%) 65 ( Figure 4 ).…”