Automatic Three-Dimensional Reconstruction of the Esophagus in Achalasia Patients undergoing POEM: a Comprehensive Assessment of Treatment Outcomes and pathophysiological Changes

Aims Achalasia is a chronic esophageal motility disorder. Peroral endoscopic myotomy (POEM) is a standard treatment option for patients with achalasia. However, treatment response varies due to factors such as achalasia type, degree of dilatation, pressure, and distensibility indices. This study presents an innovative approach for risk stratification, treatment response prediction and pathophysiological understanding based on an automatic three-dimensional (3-D) reconstruction of the tubular esophagus (TE) and the lower esophageal sphincter (LES) in patients undergoing POEM for achalasia.

Methods A software was developed, integrating data from high-resolution manometry (HRM), timed barium esophagogram (TBE), and endoscopic images, to automatically generate 3-D reconstructions of the TE and LES. Novel normative value indices for TE and LES were automatically integrated and calculated as “TE”=Volume×Pressure and “LES”=Volume/Pressure, facilitating pre- and post-POEM comparisons. Prospective data from achalasia patients undergoing POEM were used to derive volumetric and pressure indices from the 3-D reconstruction. Treatment response was evaluated by changes in volumetric and pressure indices for the TE and the LES before POEM as well as 3 and 12 months after POEM. In addition, these values were compared with normal value indices of non-achalasia patients. Geometric alterations and remodelling post-POEM were visually assessed using the 3-D reconstruction of the esophagus.

Results The study prospectively enrolled 50 treatment-naive achalasia patients. Mean TE(0) index was 3438.43±3805.64cm³*mmHg and decreased significantly 3 months after POEM to mean TE(3) index of 952.27 ± 1077.7cm³*mmHg (P<.0001). Mean LES(0) index was 0.1950±0.3605cm³/mmHg and increased significantly 3 months post-POEM to mean LES(3) index of 0.9955±0.9966cm³/mmHg (P<.0001). In the 12-months follow-up with 16 patients, mean TE(3) and mean TE(12) indices (P=.535), as well as mean LES(3) and mean LES(12) indices (P=.438) did not exhibit significant differences. 3 months post-POEM mean LES(3) index approached mean LES(N) of the healthy control group (P=.077).

Conclusions 3-D reconstruction provides an interactive, dynamic visualization of the esophagus, offering valuable insights into post-treatment remodelling and pathophysiological changes. These insights can inform our approach to achalasia treatment and optimize treatment outcomes.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024