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Patterns of postmyotomy contractility. A, Failed peristalsis in a patient with type 2 achalasia treated with Heller myotomy without fundoplication. B, Weak contraction with a large break in the 20–mm Hg isobaric contour in a patient with type 2 achalasia treated with Heller myotomy with Toupet fundoplication. The contraction had proximal and distal defects. In both patients, the pressure at the level of the esophagogastric junction (EGJ) is very low and no high-pressure zone was identified. C, Compartmentalized esophageal pressurization in a patient with type 2 achalasia treated with Heller myotomy and Dor fundoplication. The postoperative mean integrated relaxation pressure was 17 mm Hg, thereby meeting the criterion for EGJ outflow obstruction. A weak contraction with a large break in the 20–mm Hg isobaric contour was also noted. UES indicates upper esophageal sphincter. Horizontal arrows represent the time elapsed.
Source publication
Importance Although successful treatment of achalasia depends on alleviating the obstruction at the esophagogastric junction, the postintervention contractile and pressurization pattern may also play a role in outcome.
Objective To determine whether myotomy that alleviates the esophagogastric junction outflow obstruction in achalasia might improve...
Context in source publication
Context 1
... 1 illustrates examples of premyotomy and postmyotomy EPT studies of one patient with type 2 achalasia and an- other with type 3 achalasia. Examples of different pat- terns of postoperative contractile activity are illustrated in Figure 1 and Figure 2. In the context of Chicago clas- sification terms, these contractile patterns included failed peristalsis, weak contractions with large breaks in the 20- mm Hg isobaric contour, and premature contractions. ...
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Purpose of Review
High-resolution manometry (HRM) is increasingly performed worldwide, to study esophageal motility. The Chicago classification is subsequently applied to interpret the manometric findings and facilitate a diagnosis of esophageal motility disorders. This review will discuss new insights regarding the diagnosis and management using t...
Citations
... 8 Moreover, previous studies have consistently shown that a varying degree of contractility can be exhibited after treatment. [9][10][11][12] Excluding type III achalasia, wherein spastic contractility is already present yet in most cases intentionally abolished with a long myotomy, type II may be the subtype more likely to be associated with presence of contractile activity after treatment. 12 No other physiological predictors are known to date and, most importantly, whether this phenomenon carries physiological and clinical significance also remains uncertain. ...
... Most importantly, we found that post-treatment contractile activity was associated with improved esophageal emptying; column heights on follow-up TBE were significantly less in patients with contractility versus patients without con- Contractile activity after achalasia treatment has been described in several studies, with rates ranging from 27% to 57% (similar to the presently described cohort). [9][10][11][12] However, there is variability on how contractility is defined across studies. A recent study defined "peristaltic recovery" as presence of at least 3 cm isobaric contour integrity of 20 mmHg distal to the transition zone; a threshold of peristaltic vigor of uncertain relevance. ...
... portant objective clinical outcome of retention on TBE, which is an independent outcome measure from HRM or FLIP. Previous studies have suggested that contractile activity after treatment has minimal or no impact on physiological and clinical outcomes.[9][10][11][12] Our group previously showed that a subset of type II achalasia patients with high panesophageal pressurization values and FLIP pressures may F I G U R E 4 Relationship between TBE column height at 1 min (A, C) and 5 min (B, D) and median DCI, stratified by "normal" and "abnormal" EGJ metrics. ...
Background and Aims
Some achalasia patients exhibit esophageal contractile activity on follow‐up after treatment, yet its importance remains unclear. We aimed to identify factors associated with presence of contractility after treatment and to assess its impact on timed barium esophagram (TBE) and clinical outcomes.
Methods
Patients with type I or II achalasia on baseline high‐resolution manometry (HRM) who completed HRM, TBE, and functional lumen imaging probe (FLIP) after treatment were retrospectively identified. Contractility was defined on post‐treatment HRM as presence of at least 1 supine swallow with DCI ≥100 mmHg s cm.
Key Results
One hundred twenty‐two patients were included (mean age 48 ± 17 years, 50% female). At follow‐up evaluation after treatment (54% peroral endoscopic myotomy, 24% pneumatic dilation, 22% laparoscopic Heller myotomy), 61 (50%) patients had contractility on HRM. Patients with contractility (compared to those without) more frequently had type II achalasia (84% vs 57%, p = 0.001) and a post‐treatment normal EGJ opening classification on FLIP (69% vs 49%; p < 0.001). In the subgroup of patients with post‐treatment integrated relaxation pressure <15 mmHg and normal EGJ opening on FLIP (n = 53), those with contractility had a lower median column height on TBE at 1 min (4 vs 7 cm, p = 0.002) and 5 min (0 vs 5 cm, p = 0.001). In patients with “abnormal” EGJ metrics, patients with contractility showed lower symptom scores (median Eckardt score 2 vs 3, p = 0.03).
Conclusions & Inferences
Occurring more frequently in type II achalasia, and if adequate EGJ opening is achieved after treatment, esophageal contractility may contribute to improved esophageal emptying and improved symptoms in non‐spastic achalasia. Preservation of esophageal body muscle could improve outcomes in these patients.
... Records of post-intervention HRM were visually analyzed to look for the new appearance of contraction at least 3 cm in length, along the 20 mmHg isobaric contour. Such findings were considered a "pseudorecovery" of peristalsis [20,21]. Post-intervention HRM records, in which a new DL was apparent, were analyzed in detail with the help of pertinent software. ...
... These studies were small, used conventional manometry, and the contemporary definition for a normal peristalsis, which is obsolete today. Three recent studies used HRM to look for post-myotomy peristaltic patterns in AC patients [20,21,29]. In one study, the authors analyzed peristalsis in 30 patients diagnosed as AC, 20 of whom underwent LHM and 10 had POEM [20]. ...
... Three recent studies used HRM to look for post-myotomy peristaltic patterns in AC patients [20,21,29]. In one study, the authors analyzed peristalsis in 30 patients diagnosed as AC, 20 of whom underwent LHM and 10 had POEM [20]. They reported a return of peristalsis in 50% of their patients, although they did not use a standard definition of peristalsis provided by the contemporary version of CC [19]. ...
... We evaluated the predictive accuracy of a combination of HRM Our observation of 12% of a type II achalasia patients displaying post-treatment spastic contractility on HRM (per CCv4.0) was greater than reported in previous studies done after laparoscopic or endoscopic myotomy and reporting post-treatment spasm in only 0-5% of type II achalasia patients. [26][27][28] Our inclusion of a considerable number of patients treated with PD (37%), partially explains this, as we also show that PD trended to be associated with this occurrence. Nevertheless, our findings suggest that 'embedded spasm' ...
Background
Panesophageal pressurization (PEP) defines type II achalasia on high‐resolution‐manometry (HRM) but some patients exhibit spasm after treatment. The Chicago Classification (CC) v4.0 proposed high PEP values as predictor of embedded spasm, yet supportive evidence is lacking.
Methods
Fifty seven type II achalasia patients (47 ± 18 years, 54% males) with HRM and LIP Panometry before and after treatment were retrospectively identified. Baseline HRM and FLIP studies were analyzed to identify factors associated with post‐treatment spasm, defined on HRM per CC v4.0.
Results
Seven patients (12%) had spasm following treatment (peroral endoscopic myotomy 47%; pneumatic dilation [PD] 37%; laparoscopic Heller myotomy 16%). At baseline, greater median maximum PEP pressure (MaxPEP) values on HRM (77 vs 55 mmHg, p = 0.045) and spastic‐reactive contractile response pattern on FLIP (43% vs 8%, p = 0.033) were more common in patients with post‐treatment spasm while absent contractile response on FLIP was more common in patients without spasm (14% vs 66%, p = 0.014). The strongest predictor of post‐treatment spasm was the percentage of swallows with MaxPEP ≥70 mmHg (best cut‐off: ≥30%), with AUROC of 0.78. A combination of MaxPEP <70 mmHg and FLIP 60 mL pressure < 40 mmHg identified patients with lower rates of post‐treatment spasm (3% overall, 0% post‐PD) compared to those with values above these thresholds (33% overall, 83% post‐PD).
Conclusions
High maximum PEP values, high FLIP 60 mL pressures and contractile response pattern on FLIP Panometry prior to treatment identified type II achalasia patients more likely to exhibit post‐treatment spasm. Evaluating these features may guide personalized patient management.
... 20,21 Notably, esophageal contractions can be detected with Panometry even when they are not lumen occluding making them undetectable by HRM and explaining the 'recovery' of peristalsis often observe in HRM studies after achalasia treatments. 22,23 In actuality, the weak peristaltic contractions were always there but they were masked by the greater values of panesophageal pressurization attributable to EGJ outflow obstruction. ...
High-resolution manometry, Chicago Classification v4.0, the functional lumen imaging probe, Panometry, and per-oral endoscopic myotomy (POEM) are all now integral parts of the landscape for managing achalasia or, more precisely, achalasia-like syndromes. This narrative review examines the impact of these innovations on the management of achalasia-like syndromes. High-resolution manometry was the disruptive technology that prompted the paradigm shift to thinking of motility disorders as patterns of obstructive physiology involving the esophagogastric junction and/or the distal esophagus rather than as siloed entities. An early observation was that the cardinal feature of achalasia—impaired lower esophageal sphincter relaxation—can occur in several subtypes: without peristalsis, with pan-esophageal pressurization, with premature (spastic) distal esophageal contractions, or even with preserved peristalsis (esophagogastric junction outlet obstruction). Furthermore, there being no biomarker for achalasia, no manometric pattern is perfectly sensitive or specific for ‘achalasia’ and there is also no ‘gold standard’ for the diagnosis. Consequently, complimentary physiological testing with a timed barium esophagram or functional lumen imaging probe are employed both to improve the detection of patients likely to respond to treatments for ‘achalasia’ and to characterize other syndromes also likely to benefit from achalasia therapies. These findings have become particularly relevant with the development of a minimally invasive technique for performing a tailored esophageal myotomy, POEM. Now and in the future, optimal achalasia management is to render treatment in a phenotype-specific manner, that is, POEM calibrated in a patient-specific manner for obstructive physiology including the distal esophagus and more conservative strategies such as a short POEM or pneumatic dilation for obstructive physiology limited to the lower esophageal sphincter.
... Therefore, post-treatment esophageal motility recovery depends on patient characteristics. 8,9 Short symptom duration, high pretreatment IRP, and types II and III achalasia have been reported as indicators of peristalsis recovery after treatment, although discrepancies were present in these reports. [10][11][12] Despite their relevance as indicators of residual LES function impairment, patient characteristics associated with high postintervention IRP values have not been fully investigated. ...
... 29 Other reports did not mention the frequency of high IRP values but rather only documented median or mean IRP values. 6,7,[30][31][32] In contrast, peristaltic recovery rates were previously reported as 25.0% to 60.9%, 8,11,12 which were higher compared with our results. The lower frequency of high IRP values and peristalsis Values are median (interquartile range) or n (%). ...
... Low IRP values and severe esophageal dilation have been observed, particularly in advanced achalasia, 37 considered to be a type with reduced or absent ganglion cells, 38 and peristalsis is considered difficult to restore. It has been reported that myotomy of the lower esophagus was less likely to produce contractile pressure 8,39 ; however, extended myotomy length to the oral side, beyond 10 cm, may not be relevant to peristalsis recovery. ...
Background & Aims
Peroral endoscopic myotomy (POEM) is conducted for patients with esophageal motility disorders based on high-resolution manometry (HRM) findings. However, the impact of POEM on HRM findings and the associations between post-POEM HRM and outcomes have not been clarified.
Methods
In a multicenter, observational cohort study, patients with achalasia treated by POEM received follow-up HRM. Associations between patient characteristics, POEM procedures, and post-POEM HRM findings, including integrated relaxation pressure (IRP) and distal contractile integral (DCI), were investigated. Furthermore, the outcomes of the POEM procedure were compared with the post-POEM HRM findings.
Results
Of 2,171 patients, 151 (7.0%) showed residual high post-POEM IRP (≥26 mmHg, Starlet). In a multivariate analysis, high pre-POEM IRPs (odds ratio [OR]=24.3) and gastric myotomy >2 cm (OR=0.22) were found to be positive and negative predictive factors of high post-POEM IRPs, respectively. Peristalsis recovery (DCI ≥500 mmHg-cm-sec, at least one swallow, Starlet) was visible in 121 (19.6%) of 618 patients, and they were type II-III achalasia. High pre-POEM IRP (OR=2.65) and DCI ≥500 (OR=2.98) predicted peristalsis recovery, while esophageal dilation (OR=0.42) predicted a risk of no recovery. Extended myotomy did not reveal a significant impact on peristalsis recovery. High or low post-POEM IRP and DCI did not increase the incidence of clinical failure, reflux esophagitis, or symptomatic gastroesophageal reflux disease.
Conclusions
Extended gastric myotomy decreased IRP values, while peristalsis recovery depended on the characteristics of achalasia. A residual high post-POEM IRP does not necessarily mean clinical failure. Routine HRM follow-up is not recommended after POEM.
... 15 Moreover, it is unclear which parameters can predict symptomatic improvement and the presence of esophageal peristalsis after POEM treatment. 16,17 The aim of this study is to investigate the clinical significance of panometry before POEM and determine the predictive parameters of symptomatic improvement and presence of esophageal peristalsis after POEM. ...
... The presence of contractility (POC) using esophageal HRM after POEM was defined by 2 investigators (K.W.J. and L.C.H.) after discussion. 16 ...
... 22 Secondary outcomes assessed before and after POEM included the following: the gastroesophageal reflux disease questionnaire (GerdQ), basal LES pressure, IRP, POC based on HRM findings, procedure time, length of myotomy, EGJ-DI, and follow-up panometry. 16 ...
Background/aims:
We evaluated the clinical significance and prognostic power of functional luminal imaging probe (FLIP) panometry in patients with achalasia treated with peroral endoscopic myotomy (POEM), and examined the clinical parameters associated with symptomatic improvement and the presence of contractility (POC) following POEM.
Methods:
We reviewed the electronic medical records of patients with achalasia treated with FLIP panometry and POEM at a tertiary teaching hospital in Seoul, Republic of Korea. Follow-up examination was composed of esophageal manometry and questionnaires on symptoms. We analyzed the FLIP data by interpolating using the cubic spline method in MATLAB.
Results:
We retrospectively analyzed 33 men and 35 women (mean age: 52 ± 17 years), of whom 14, 39, and 15 patients were diagnosed with achalasia types I, II, and III, respectively. The FLIP panometry diagnoses were reduced esophagogastric junction opening (REO) with a retrograde contractile response (n = 43); REO with an absent contractile response (n = 5); REO with a normal contractile response (n = 11); and a retrograde contractile response (n = 9). Overall, the patients showed improvements in Eckardt scores following POEM from 6.48 ± 2.20 to 1.16 ± 1.15 (P < 0.01). Post-POEM symptomatic improvement was not significantly associated with any of the clinical parameters, including panometry diagnosis. Conversely, post-POEM POC was significantly associated with the presence of repetitive antegrade contractions and achalasia subtypes (both P < 0.01).
Conclusion:
While FLIP panometry was not significantly associated with the clinical course of achalasia, FLIP panometry was associated with POC following POEM and may complement manometry in the functional evaluation of esophageal motility disorders.
... Regarding the length of the myotomy, observational studies suggest that shorter overall myotomy (5-6 cm) and shorter cardio-myotomy (≤ 2 cm) is highly effective with perhaps less gastroesophageal reflux disease (GERD) [4,5]. A shorter myotomy is easier and quicker to perform with less disruption to the non-obstructive segment of the esophagus, which will minimize the risk of deleterious effects on peristalsis and luminal dilation [6]. The extent of the myotomy Fig. 1 POEM in 66-year-old woman with type II achalasia. ...
Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker’s diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel “3rd space endoscopy” field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our “ultra-short tunnel technique”. Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.
... However, the underlying abnormality in peristalsis is not addressed with such treatment modalities with goal of treatment to prevent further progression of the disorder. Similarly, treatment of achalasia, a major disorder of peristalsis, is focused on interventions targeting esophagogastric junctional obstruction such as myotomy, pneumatic dilation, or botulinum toxin injection, with only partial return of esophageal peristalsis seen afterward [20]. ...
Weak or absent peristalsis of the esophageal musculature is a common finding in ambulatory patients suffering from dysphagia and frequently associated with gastroesophageal reflux. There is currently no pharmacologic intervention that reliably improves esophageal contractility in patients suffering from various esophageal motility disorders. Our objective was to evaluate the acute effects of pyridostigmine on high-resolution manometry parameters in patients suffering from dysphagia with evidence of esophageal dysmotility. Pyridostigmine is an acetylcholinesterase inhibitor which increases effective concentrations of acetylcholine at the neuromuscular junction of both striated and smooth muscle cells. We conducted a prospective crossover study of five patients with dysphagia and proven esophageal dysmotility. Three patients had baseline ineffective esophageal motility and two had achalasia. Patients underwent pharyngeal and esophageal manometry before and after pyridostigmine administration. The median distal contractile integral (DCI), a marker of esophageal contractile vigor, was significantly higher post pyridostigmine administration 3001 (1950.3–3703.2) mmHg × s × cm compared to pre-pyridostigmine DCI of 1229.9 (956.2–2100) mmHg × s × cm; P < 0.001. Pre-pyridostigmine 18/25 (72%) of the patient’s swallows was peristaltic compared to 25/25 (100%) post-pyridostigmine; P < 0.005. No other pharyngeal or esophageal high-resolution manometry parameter differed significantly after pyridostigmine administration. The results of this pilot study demonstrate that pyridostigmine acutely improves esophageal contractile vigor in patients suffering from dysphagia with esophageal dysmotility. Further investigation with larger sample size, longer follow-up, side effect profile, and patient-reported outcome measures is still needed to determine the clinical usefulness of pyridostigmine in specific disorders of esophageal motility.
... The answer to this hypothesis will provide useful information for deciding the treatment strategy for achalasia, such as the length of myotomy, as well as for providing essential evidence for applying POEM in spastic esophageal motility disorders other than type III achalasia, such as jackhammer esophagus and distal esophageal spasm, in which LES relaxation during primary peristalsis is intact and the main pathophysiology is confined to the esophageal body. 11 However, studies on changes in esophageal body movement after POEM are limited 12 and based on timed barium esophagography, which provides indirect information about esophageal bolus transit. 13 The recently introduced functional imaging probe was reported to provide clinically useful information about esophageal distensibility after POEM, but it has limitations in providing primary peristalsis data. ...
... Although it is still debated whether the unique esophageal body motility pattern is caused by primary myopathy of the esophageal body or is secondary to increased intrabolus pressure, our results suggest that effective LES decompression alone can normalize the PEP in type II achalasia. 12 Based on our results in type I and II achalasia, we cautiously propose that long myotomy is not necessarily essential in type I and II achalasia and that POEM with short myotomy, which ensures complete LES myotomy, can be as effective as POEM with long myotomy. 34 Our study has several inevitable methodologic limitations. ...
Background/aims:
The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia.
Methods:
Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed.
Results:
The MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group.
Conclusions:
POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.
... Recently, partial peristaltic recovery after myotomy (either laparoscopic or endoscopic) in a considerable number of patients with achalasia has been described suggesting that EGJOO plays a role in occurrence of failed peristalsis in at least some patients with achalasia. [11][12][13][14][15][16][17][18] Whether there are any predictors of peristaltic recovery and whether this phenomenon is clinically relevant is unknown. ...
... Recently, several rather small studies addressed the issue of possible recovery of peristalsis after myotomy either laparoscopic or endoscopic, most of them predominantly focusing on the measured HRM parameters (IRP and LESP). 12,14,15,21 But the phenomenon of peristaltic recovery after alleviating the obstruction of EGJ has already been observed in the past including both clinical and experimental settings. [9][10][11]13,17,18 In our study we have shown, that the esophageal contractions were observed in 28.7% of patients after POEM including cases who had some preserved peristalsis also before POEM (achalasia type III), thus the true "recovery" with the newly appeared contractions was observed in 22.0%. ...
... Therefore, knowing the initial diagnosis and the intervention, we believe the measures of the main HRM parameters can be compared and the CC applied as it was used elsewhere. 12 Second, for the purpose of our study we used the term "peristaltic recovery." Obviously, it harbors inaccuracy in the term "peristaltic" because we cannot assess accurately enough whether these "recovered" contractions are truly peristaltic, ie, have the potential to propel the bolus distally. ...
Background/aims:
Several studies have reported partial recovery of peristalsis in patients with achalasia after myotomy. The aim of our study is to analyze esophageal motility patterns after peroral endoscopic myotomy (POEM) and to assess the potential predictors and clinical impact of peristaltic recovery.
Methods:
We performed a retrospective analysis of prospectively collected data of consecutive patients with achalasia undergoing POEM at a tertiary center. High-resolution manometry (HRM) studies prior to and after POEM were reviewed and the Chicago classification was applied.
Results:
A total of 237 patients were analyzed. The initial HRM diagnoses were achalasia type I, 42 (17.7%); type II, 173 (73.0%); and type III, 22 (9.3%). Before POEM, peristaltic fragments were present in 23 (9.7%) patients. After POEM the Chicago classification diagnoses were: 112 absent contractility, 42 type I achalasia, 15 type II, 11 type III, 26 ineffective esophageal motility, 18 esophagogastric junction outflow obstruction, 10 fragmented peristalsis, and 3 distal esophageal spasm. Altogether 68 patients (28.7%) had signs of contractile activity, but the contractions newly appeared in 47 patients (47/214, 22.0%). Type II achalasia showed a trend for appearance of contractions (P = 0.097). Logistic regression analysis did not identify any predictors of peristaltic recovery. The post-POEM Eckardt score did not differ between patients with and without contractions nor did the parameters of timed barium esophagogram.
Conclusions:
More than 20% of achalasia patients have signs of partial recovery of esophageal peristalsis after POEM. It occurs predominantly in type II achalasia but the clinical relevance seems to be negligible.
