Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response

Abstract

Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes.

Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %–49 %), 3 (50 %–89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm²/mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time.

Results Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2–4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2–4 (95.7 % vs. 60 %, P = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar.

Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

Publikationsverlauf

Eingereicht: 17. März 2021

Angenommen: 22. Juni 2021

Artikel online veröffentlicht:
12. November 2021

• References

• 1 Vaezi MF, Pandolfino JE, Yadlapati RH. et al. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Am J Gastroenterol 2020; 115: 1393-1411
• 2 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019; 381: 2219-2229
• 3 Ponds FA, Fockens P, Lei A. et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 2019; 322: 134-144
• 4 Levy JL, Levine MS, Rubesin SE. et al. Findings of esophagography for 25 patients after peroral endoscopic myotomy for achalasia. AJR Am J Roentgenol 2016; 207: 1185-1193
• 5 El Khoury R, Teitelbaum EN, Sternbach JM. et al. Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM). Surg Endosc 2016; 30: 2969-2974
• 6 Nast JF, Berliner C, Rösch T. et al. Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM). Surg Endosc 2018; 32: 3956-3963
• 7 Reddy CA, Tavakkoli A, Abdul-Hussein M. et al. Clinical impact of routine esophagram after peroral endoscopic myotomy. Gastrointest Endosc 2021; 93: 102-106
• 8 Pannu D, Yang D, Abbitt PL. et al. Prospective evaluation of CT esophagram findings after peroral endoscopic myotomy. Gastrointest Endosc 2016; 84: 408-415
• 9 Cai MY, Zhou PH, Yao LQ. et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014; 80: 1046-1055
• 10 de Oliveira JM, Birgisson S, Doinoff C. et al. Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia. AJR Am J Roentgenol 1997; 169: 473-479
• 11 Vaezi MF, Baker ME, Richter JE. Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram. Am J Gastroenterol 1999; 94: 1802-1807
• 12 Vaezi MF, Baker ME, Achkar E. et al. Timed barium oesophagram: better predictor of long-term success after pneumatic dilation in achalasia than symptom assessment. Gut 2002; 50: 765-770
• 13 Sternbach JM, El Khoury R, Teitelbaum EN. et al. Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes. Surgery 2015; 158: 1128-1135 ; discussion 1135-1136
• 14 Sanaka MR, Chadalavada P, Covut F. et al. Clinical success and correlation of eckardt scores with barium esophagram after peroral endoscopic myotomy in achalasia. J Gastrointest Surg 2021; 25: 278-281
• 15 Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103: 1732-1738
• 16 Kahrilas PJ, Bredenoord AJ, Fox M. et al. International High Resolution Manometry Working Group. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil 2015; 27: 160-174
• 17 Pandolfino JE, de Ruigh A, Nicodème F. et al. Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP™) in achalasia patients. Neurogastroenterol Motil 2013; 25: 496-501
• 18 Roll GR, Rabl C, Ciovica R. et al. A controversy that has been tough to swallow: is the treatment of achalasia now digested?. J Gastrointest Surg 2010; 14: S33-S45
• 19 Lundell LR, Dent J, Bennett JR. et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999; 45: 172-180
• 20 Lawenko RM, Lee YY. Evaluation of gastroesophageal reflux disease using the bravo capsule pH system. J Neurogastroenterol Motil 2016; 22: 25-30
• 21 Gyawali CP, Kahrilas PJ, Savarino E. et al. Modern diagnosis of GERD: the Lyon Consensus. Gut 2018; 67: 1351-1362
• 22 Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103: 1732-1738
• 23 Carlson DA, Kou W, Lin Z. et al. Normal values of esophageal distensibility and distension-induced contractility measured by functional luminal imaging probe panometry. Clin Gastroenterol Hepatol 2019; 17: 674-681
• 24 Kostic SV, Rice TW, Baker ME. et al. Timed barium esophagogram: A simple physiologic assessment for achalasia. J Thorac Cardiovasc Surg 2000; 120: 935-943
• 25 Tsoukali E, Gouvas N, Tsiaoussis J. et al. Specific esophagogram to assess functional outcomes after Hellerʼs myotomy and Dorʼs fundoplication for esophageal achalasia. Dis Esophagus 2011; 24: 451-457
• 26 Andersson M, Lundell L, Kostic S. et al. Evaluation of the response to treatment in patients with idiopathic achalasia by the timed barium esophagogram: results from a randomized clinical trial. Dis Esophagus 2009; 22: 264-273
• 27 Kachala SS, Rice TW, Baker ME. et al. Value of routine timed barium esophagram follow-up in achalasia after myotomy. J Thorac Cardiovasc Surg 2018; 156: 871-877
• 28 Oezcelik A, Hagen JA, Halls JM. et al. An improved method of assessing esophageal emptying using the timed barium study following surgical myotomy for achalasia. J Gastrointest Surg 2009; 13: 14-18
• 29 Zanoni A, Rice TW, Lopez R. et al. Timed barium esophagram in achalasia types. Dis Esophagus 2015; 28: 336-344
• 30 Vela MF, Richter JE, Khandwala F. et al. The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia. Clin Gastroenterol Hepatol 2006; 4: 580-587
• 31 Blam ME, Delfyett W, Levine MS. et al. Achalasia: a disease of varied and subtle symptoms that do not correlate with radiographic findings. Am J Gastroenterol 2002; 97: 1916-1923
• 32 Shah R, Cai Q. Clinical utility of routine post-peroral endoscopic myotomy imaging: Does clinical decision making outweigh the protocol. Gastrointest Endosc 2021; 93: 107-109
• 33 Foisy H, Pioche M, Chabrun E. et al. Role of rapid drink challenge during esophageal high-resolution manometry in predicting outcome of peroral endoscopic myotomy in patients with achalasia. J Neurogastroenterol Motil 2020; 26: 204-214