Comparison of functional lumen imaging probe and high-resolution manometry to assess response after peroral endoscopic myotomy

Published:December 31, 2021DOI:https://doi.org/10.1016/j.gie.2021.12.029

      Background and Aims

      Outcomes after peroral endoscopic myotomy (POEM) are assessed clinically by the Eckardt score (ES) or objectively by high-resolution manometry (HRM) and functional lumen imaging probe (FLIP). This study compared HRM and FLIP to evaluate clinical response after POEM.

      Methods

      This was a single tertiary center retrospective study of consecutive patients who underwent POEM for treatment-naive achalasia and with ≥6 months of follow-up. Baseline and follow-up testing in all patients included ES, HRM, and FLIP of the esophagogastric junction (EGJ). A normal post-POEM (or normalized) EGJ distensibility index (EGJ-DI) >2.8 mm2/mm Hg, maximum EGJ diameter (MxEGJD) ≥14 mm, and integrated relaxation pressure (IRP) <15 mm Hg were compared with a clinical response, defined as ES ≤3.

      Results

      Eighty-seven patients (58% men, mean age 51 ± 17 years) were included. Overall clinical response by ES, IRP, MxEGJD, and EGJ-DI were 97.7%, 86.2%, 75.9%, and 92.0%, respectively. The sensitivity of a normal IRP (87.1% [95% confidence interval {CI}, 78.0-93.4]) was similar to the sensitivity of a normal MxEGJD (75.3% [95% CI, 64.7-84.0], P = .053) and normal EGJ-DI (91.8% [95% CI, 83.8%-96.6%], P = .39) after POEM to predict clinical response. However, the sensitivity of a normal post-POEM EGJ-DI was superior to a normal post-POEM MxEGJD (P = .001) to predict clinical response. There was no difference in the area under the curve of a normal MxEGJD or EGJ-DI to predict a normal IRP (P = .956) after POEM.

      Conclusions

      Normal FLIP metrics ≥6 months after POEM for achalasia show good to excellent sensitivity but are equivalent to a normalized IRP by HRM to predict clinical response by ESs. FLIP may be used as an alternative to HRM to assess lower esophageal sphincter response to POEM in these patients. (Clinical trial registration number: NCT02770859.)

      Graphical abstract

      Abbreviations:

      AUC (area under the curve), EGJ (esophagogastric junction), EGJ-DI (esophagogastric junction distensibility index), ES (Eckardt score), FLIP (functional lumen imaging probe), HRM (high-resolution manometry), IRP (integrated relaxation pressure), LES (lower esophageal sphincter), MxEGJD (maximum esophagogastric junction diameter), POEM (peroral endoscopic myotomy)
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      References

        • Vaezi M.F.
        • Pandolfino J.E.
        • Yadlapati R.H.
        • et al.
        ACG clinical guidelines: diagnosis and management of achalasia.
        Am J Gastroenterol. 2020; 115: 1393-1411
        • Werner Y.B.
        • Hakanson B.
        • Martinek J.
        • et al.
        Endoscopic or surgical myotomy in patients with idiopathic achalasia.
        N Engl J Med. 2019; 381: 2219-2229
        • Ponds F.A.
        • 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
        • Eckardt V.F.
        • Aignherr C.
        • Bernhard G.
        Predictors of outcome in patients with achalasia treated by pneumatic dilation.
        Gastroenterology. 1992; 103: 1732-1738
        • Nicodème F.
        • de Ruigh A.
        • Xiao Y.
        • et al.
        A comparison of symptom severity and bolus retention with Chicago classification esophageal pressure topography metrics in patients with achalasia.
        Clin Gastroenterol Hepatol. 2013; 11: 131-137
        • Ghosh S.K.
        • Pandolfino J.E.
        • Rice J.
        • et al.
        Impaired deglutitive EGJ relaxation in clinical esophageal manometry: a quantitative analysis of 400 patients and 75 controls.
        Am J Physiol Gastrointest Liver Physiol. 2007; 293: G878-G885
        • Ju H.
        • Ma Y.
        • Liang K.
        • et al.
        Function of high-resolution manometry in the analysis of peroral endoscopic myotomy for achalasia.
        Surg Endosc. 2016; 30: 1094-1099
        • Vaezi M.F.
        • Baker M.E.
        • Richter J.E.
        Assessment of esophageal emptying post-pneumatic dilation: use of the timed barium esophagram.
        Am J Gastroenterol. 1999; 94: 1802-1807
        • Vaezi M.F.
        • Baker M.E.
        • 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
        • Levy J.L.
        • Levine M.S.
        • Rubesin S.E.
        • et al.
        Findings of esophagography for 25 patients after peroral endoscopic myotomy for achalasia.
        AJR Am J Roentgenol. 2016; 207: 1185-1193
        • Sternbach J.M.
        • El Khoury R.
        • Teitelbaum E.N.
        • et al.
        Early esophagram in per-oral endoscopic myotomy (POEM) for achalasia does not predict long-term outcomes.
        Surgery. 2015; 158 (discussion 1135-6): 1128-1135
        • Sanaka M.R.
        • 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
        • DeWitt J.
        • Siwiec R.
        • Perkins A.
        • et al.
        Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response.
        Endosc Int Open. 2021; 9: E1692-E1701
        • Savarino E.
        • di Pietro M.
        • Bredenoord A.J.
        • et al.
        Use of the functional lumen imaging probe in clinical esophagology.
        Am J Gastroenterol. 2020; 115: 1786-1796
        • Pandolfino J.E.
        • 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
        • Rohof W.O.
        • Hirsch D.P.
        • Kessing B.F.
        • et al.
        Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction.
        Gastroenterology. 2012; 143 (328-3)
        • Su B.
        • Callahan Z.M.
        • Novak S.
        • et al.
        Using impedance planimetry (EndoFLIP) to evaluate myotomy and predict outcomes after surgery for achalasia.
        J Gastrointest Surg. 2020; 24: 964-971
        • Holmstrom A.L.
        • Campagna R.A.J.
        • Cirera A.
        • et al.
        Intraoperative use of FLIP is associated with clinical success following POEM for achalasia.
        Surg Endosc. 2021; 35: 3090-3096
        • Moran R.A.
        • Brewer Gutierrez O.I.
        • Rahden B.
        • et al.
        Impedance planimetry values for predicting clinical response following peroral endoscopic myotomy.
        Endoscopy. 2021; 53: 570-577
        • Yoo I.K.
        • Choi S.A.
        • et al.
        Assessment of clinical outcomes after peroral endoscopic myotomy via esophageal distensibility measurements with the endoluminal functional lumen imaging probe.
        Gut Liver. 2019; 13: 32-39
        • Ngamruengphong S.
        • von Rahden B.H.
        • Filser J.
        • et al.
        Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study.
        Surg Endosc. 2016; 30: 2886-2894
        • Kahrilas P.J.
        • Bredenoord A.J.
        • 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
        • Carlson D.A.
        • 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
        • Jain A.S.
        • Carlson D.A.
        • Triggs J.
        • et al.
        Esophagogastric junction distensibility on functional lumen imaging probe topography predicts treatment response in achalasia-anatomy matters!.
        Am J Gastroenterol. 2019; 114: 1455-1463
        • Teitelbaum E.N.
        • Soper N.J.
        • Pandolfino J.E.
        • et al.
        Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes.
        Surg Endosc. 2015; 29: 522-528
        • Ofosu A.
        • Mohan B.P.
        • Ichkhanian Y.
        • et al.
        Peroral endoscopic myotomy (POEM) vs pneumatic dilation (PD) in treatment of achalasia: a meta-analysis of studies with ≥12-month follow-up.
        Endosc Int Open. 2021; 9: E1097-E1107
        • Holmstrom A.L.
        • Campagna R.J.
        • Carlson D.A.
        • et al.
        Comparison of preoperative, intraoperative, and follow-up functional luminal imaging probe measurements in patients undergoing myotomy for achalasia.
        Gastrointest Endosc. 2021; 94: 509-514