Assessment of Esophageal Emptying in Patients with Dysphagia: Differences Between High-Resolution Impedance Manometry and Timed Barium Esophagram.

Background/Aims: Assessment of esophageal emptying is important in the evaluation of patients with dysphagia. As several modalities can evaluate this, we aimed to compare two tests frequently used for assessing esophageal emptying—highresolution impedance manometry (HRiM) and timed barium esophagram (TBE). Methods: A retrospective study compared the results of HRiM and TBE in patients with dysphagia between 2018 and 2022. Abnormal esophageal clearance was defined as ≥30% swallows with incomplete bolus clearance on HRiM and as residual barium ≥2 cm at 5 minutes on TBE. Results: 77 patients were included in the study (mean age 51.6; 69% female). The most common HRiM diagnoses were normal motility (37.7%), ineffective esophageal motility (28.6%), and achalasia (19.5%). Effective esophageal clearance was noted on HRiM in only 44 subjects (57.1%), while it was seen on TBE in 57 subjects (74.0%)(P=0.027). There was agreement between the studies in 58 subjects (75.3%). Agreement was significantly affected by the HRiM diagnosis with the highest rate (86.7%) among achalasia patients (P=0.032). The only other factor correlated to agreement between the studies was a lack of alcohol use (P=0.048). Conclusions: According to the parameters used in this study, TBE is more likely to reveal esophageal emptying than HRiM in patients with dysphagia. While there is fair agreement between the results of the two studies, results are especially concordant in achalasia patients suggesting that either study may be useful in evaluating esophageal emptying in that population.

The objective measurement for esophageal bolus volume and bolus clearance could classify abnormal high-resolution manometry (HRM) beyond the current Chicago classification. We aimed to compare the novel four-dimensional impedance manometry (4D HRM) volume metrics with timed barium esophagram (TBE). Adults with esophageal symptoms undergoing HRM and TBE were included. A custom-built program for 4D HRM analysis measured esophageal luminal cross-sectional area (CSA) from impedance and subsequently derived esophageal bolus volume and clearance. 4D HRM volume metrics included pre-swallow residual volume, maximal volume, retention volume, and clearance ratio defined as 1.0-retention volume divided by the maximal volume. An abnormal TBE was defined as a column height >5 cm at 1 min or 5 min. A total of 95 patients (normal motility: 33%; ineffective esophageal motility: 12%; absent contractility: 10%; esophagogastric junction outflow obstruction: 30%; type I achalasia: 5%; type II achalasia: 12%) were categorized into normal TBE (58%), abnormal TBE at 1 min (17%), and abnormal TBE at 5 min (25%). The AUROC demonstrated that, among all 4D HRM volume metrics, the clearance ratio had the best performance in predicting abnormal TBE at 5 min (AUROC, 95% confidence interval: 0.89, 0.82-0.96), and exhibited a strong negative correlation with TBE at 5 min (r = -0.65; p < 0.001). Novel 4D HRM volume metrics provide objective measurement of esophageal bolus volume and bolus clearance. The clearance ratio has a strong correlation with TBE and could potentially serve as a substitute for TBE to measure esophageal retention.

M1152 Integrity of Esophageal Emptying in Spasm Patients: A High-Resolution Impedance Manometry Study

Pneumatic dilation or myotomy for achalasia?

Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.

Introduction: Timed barium esophagram (TBE) is used for objective assessment of esophageal emptying function in achalasia. Improvement in emptying after pneumatic dilation and Heller myotomy for achalasia have been shown to predict long term symptom relief. Peroral endoscopic myotomy (POEM) is an emerging treatment for achalasia combining the efficacy of surgical myotomy with an incisionless endoscopic procedure. Data on objective assessment of esophageal emptying by TBE after POEM is limited. Purpose of this study was to assess the improvement in esophageal emptying by TBE after POEM in patients with achalasia. Methods: Data on consecutive patients who had POEM for achalasia from April 2014 to April 2015 was collected from our Institutional Review Board approved prospective registry. Our patients routinely get TBE and high resolution esophageal manometry (HREM) before and 2 months after POEM. For TBE, patients were instructed to drink up to 230 ml of low density barium sulfate suspension (60% weight/volume) in upright position (volume of barium sulfate suspension ingested is based on patient tolerance). Then radiographs of the esophagus were taken at 1, 2 and 5 minutes with measurement of height and width of the barium column. Patient demographics, pre-and post-POEM symptoms by Eckardt scores and results of HREM and TBE at 2 month follow-up were analyzed. Data are presented as mean + standard deviation, median (P25, P75) or N (%). Differences between pre- and post-POEM were assessed with onesample t-test, non-parametric Wilcoxan signed rank test and test of symmetry. P < 0.05 was considered significant. Results: POEM was performed in 32 patients. Mean age of patients was 56 + 17 years and 56% were males. There was a significant decrease in all parameters of TBE except barium column height at minute 1. There was also significant improvement in Eckardt scores and LES pressures. Table 1 shows paired analysis assessing the changes in TBE, HREM and Eckardt symptom scores in patients who had tests done pre and post POEM at 2 month follow-up.Table 1: Pre vs. Post POEM characteristics in patients with 2-month follow-upConclusion: Esophageal emptying on TBE improves significantly after POEM in patients with achalasia. Similarly Eckardt symptom scores and LES pressures improve after POEM. Based on our TBE findings after POEM, we predict that POEM will provide durable long term symptom relief in patients with achalasia. However, further studies with long term follow-up are needed to confirm this.

Functional lumen imaging probe (FLIP) utility is established in treatment-naïve achalasia but less clear following lower esophageal sphincter (LES) directed therapy. Achalasia patients with LES directed therapy across three tertiary care centers between 2017 and 2024 with post-treatment FLIP and timed barium esophagram (TBE) were retrospectively identified. Reduced esophagogastric junction (EGJ) opening was defined by distensibility index (DI) < 2 mm2/mmHg and diameter < 12 mm. Abnormal emptying on TBE was defined as column height ≥ 5 cm at 5 min and/or retained tablet. Eckardt scores ≤ 3 defined clinical response. The study included 222 patients (46% peroral endoscopic myotomy, 46% laparoscopic Heller myotomy, 8% pneumatic dilation) with a median of 1.4 years to post-treatment TBE/FLIP. Abnormal emptying on TBE was associated with a narrower median EGJ diameter (13.2 vs. 14.8 mm, p = 0.008), a greater frequency of EGJ diameter < 12 mm (36% vs. 21%, p = 0.012), and a smaller change in EGJ diameter (+4.6 vs. +8.6 mm, p = 0.002). Abnormal emptying on TBE occurred more frequently in patients with EGJ DI < 2 mm2/mmHg (8.5% vs. 2.6%, p = 0.052), but was not associated with median EGJ DI (4.5 vs. 5.1 mm2/mmHg, p = 0.29) nor median change in EGJ DI (+2.9 vs. +3.9 mm2/mmHg, p = 0.25). Patients with reduced EGJ DI or EGJ diameter more often had abnormal TBE (37% vs. 22%, p = 0.012). Only the change in DI (+3.8 vs. +1.5 mm2/mmHg, p = 0.012) and diameter (+8.2 vs. +1.6 mm, p = 0.002) on FLIP was associated with a clinical response based on Eckardt ≤ 3. FLIP following achalasia therapy generally correlates with TBE, although discrepant findings are not uncommon. In particular, FLIP EGJ-diameter has a strong association with esophageal emptying on TBE. Both TBE and FLIP have limited association with clinical response based on Eckardt, with change in DI and diameter on FLIP most strongly associated. Consequently, FLIP as part of multimodal assessment appears useful in the longitudinal follow-up of treated achalasia.

The aim of this study was to assess whether high-resolution impedance manometry (HRIM) could be used to assess bolus retention similar to the timed barium esophagram (TBE). Twenty achalasia patients (10 males, aged 21-79 years) were prospectively evaluated with HRIM and TBE to determine the correlation between barium column height and the impedance bolus height (IBH). The TBE protocol used a 200-ml barium challenge and the HRIM protocol used a 200-ml saline challenge protocol. Both protocols were performed in an upright position and the heights of the barium and impedance columns were measured at 1 and 5 min. Analysis of IBH was performed with a topographic technique and a spatial impedance variation plot. There was no significant difference between the median IBH and barium column at 1 min (IBH: 12.0 cm (interquartile range (IQR), 8.0-18.0); TBE: 12.0 cm (IQR, 7.0-19.0); P=0.90) or at 5 min (IBH: 11.0 cm (IQR, 1.0-17.0); TBE: 9.0 cm (IQR, 4.0-12.0); P=0.47). In addition, the correlation between the two measurements at 1 and 5 min was 0.60 and 0.86, respectively. Using a barium column or impedance height of >5.0 as a definition of bolus retention was associated with 75% concordance at 1 min and 95% concordance at 5 min. There was excellent agreement between TBE and high-resolution impedance manometry (HRIM) for assessing bolus retention at 5 min. Thus, HRM with impedance may be used as a single test to assess bolus retention and motor function in the management of achalasia.

BackgroundThe aetiology and clinical impact of ineffective oesophageal motility (IEM) remain poorly understood, but the condition is thought to worsen supine gastro-oesophageal acid reflux (GERD).AimsIn this retrospective cohort analysis of...

INTRODUCTION: Symptomatic relief by Eckardt scores is used to assess treatment success after per-oral endoscopic myotomy (POEM). However, it is unclear if symptomatic improvement correlates with objective esophageal emptying on timed barium esophagram (TBE). Hence, our study aims were to identify the trends and correlation between Eckardt scores and TBE parameters after POEM. METHODS: Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients who underwent timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) prior to POEM along with two-month post-POEM, TBE and HREM were included. Demographics and procedural details, TBE, HREM and Eckardt scores were reviewed. Post-POEM Eckhardt score of ≤3 was considered as successful palliation of symptoms. Trends in Eckardt scores and TBE parameters were identified and their association was analyzed. Statistical tests were performed using linear mixed effects and longitudinal modeling. RESULTS: A total of 219 patients underwent POEM with a median follow up duration of 2.6 months [Q1-3: 2.2 to 13.7 months]. Baseline patient characteristics and outcomes are described in Table 1. Improvement in Eckardt scores was stable over 24 months, however symptoms were lowest at 3-6 months after POEM (Figure 1a). TBE width at 1 and 5 minutes were lowest at 6-9 months after POEM, however TBE width gradually returns to baseline around 18-21 months even becoming worse than baseline levels (Figure 1b,c). Lower esophageal sphincter-Integrated relaxation pressure (LES-IRP) improvement was stable over 15 months, however this parameter was limited by number of patients undergoing follow up testing (n = 62). BMI increases slightly but remains around baseline for 24 months (Figure 1d). Among the 4 TBE parameters assessed, Eckardt scores correlates the most with barium column width at 5 minutes and the degree of correlation is moderate (Figure 2). CONCLUSION: Although patients continue to have symptomatic relief after POEM, objective parameters of esophageal emptying on TBE return to pre-operative levels or even worsen around two years after POEM. Eckardt scores correlate the most with barium column width at 5-minutes on TBE. Our findings suggest that barium column width at 5 minutes on TBE might be a useful objective marker for treatment response in the mid to long-term follow up after POEM.

Timed barium esophagram (TBE) is a fluoroscopic study that is widely employed as an adjunctive tool for diagnosing esophageal emptying disorders in adults (eg, achalasia, esophagogastric junction outflow obstruction [EGJOO]) and for following response to treatment. We aimed to describe the characteristics and feasibility of a pediatric TBE protocol and provide a first report of the potential value of TBE for assessment of esophageal emptying in the pediatric population. Retrospective chart review of pediatric patients at a tertiary pediatric hospital who underwent TBE from October 2017 to October 2019. Patient and test characteristics were summarized using descriptive statistics. Results from patients who had both TBE and high-resolution esophageal manometry (HRM) were used to generate ROC curves for TBE to identify esophageal emptying disorders. Twenty-two patients underwent 25 TBE. Fourteen of 23 (61%) received 150 mL barium volume per protocol. Nearly half (42%) of subjects could tolerate ingesting barium within 20 seconds. Nine individuals underwent HRM. The sensitivity of standard adult TBE criteria (1 cm barium column height at 5 minutes) to detect emptying disorder was 100%, specificity 40%. A modified diagnostic cutoff (1.6 cm height at 5 minutes) offered 100% sensitivity, 80% specificity. TBE is feasible and should be considered an adjunctive noninvasive screen for impaired esophageal emptying in children. There was heterogeneous adherence to protocol for timing and volume of barium; however, studies remained interpretable. This population may benefit from different diagnostic cutoffs than adults, and clinical judgment should be used until specific diagnostic cutoffs are determined in children.

BackgroundEsophageal involvement is common in dermatomyositis (DM), occurring in up to 54% of patients [1]. It can lead to severe complications, such as malnutrition and aspiration pneumonia. Therefore, esophageal assessment...

Improved Assessment of Bolus Clearance in Patients With Achalasia Using High-Resolution Impedance Manometry

Background Routine timed barium esophagram (TBE), before and after Heller myotomy and Dor funduplication for achalasia, could offer the unique opportunity to objectively measure the outcome of the surgical procedure. In an initial single center experience we aimed at comparing pre-operative and post-operative TBE to objectively measure esophageal emptying and dilation, and to look for possible factors related to surgery results. Methods From 2016 to 2017, 11 patients underwent Heller myotomy and Dor funduplication for achalasia at a single center; all had a pre-operative and post-operative TBE after one month of surgery. TBE measured height and width of barium column at 1 and 5 minutes. All patients were staged according to radiological achalasia staging system: 1 patient was stage 1 (pre-operative esophageal width between 2 and 3 cm), 4 stage 2 (4–6 cm) and 6 stage 3 (&gt; 6 cm). TBE height and width at 1 and 5 minutes were compared between pre-operative and post-operative TBE by the Wilcoxon signed-rank test. Moreover the association between surgery results and possible risk factors was evaluated by Spearman's rho. Results TBE height and width at 1 minute decreased in median by 79% (range 17–100%) and 57% (37–100%), respectively, from pre-operative to post-operative TBE. The decrease was more pronounced at 5 minutes, where it was 85% (40–100%) and 71% (40–100%), respectively. Although all patients reported a significant subjective improvement in symptoms, radiological stage was associated to esophageal emptying: the 4 subjects in stage 2 and the subject in stage 1 had complete or near complete emptying at 5 minutes, while the 6 patients in stage 3 had a median percent decrease at 5 min in height of 75% (40–86%) and in width of 50% (40–71%) (Spearman's rho for height = -0.87, P &lt; 0.001; Spearman's rho for width = -0.88, P &lt; 0.001). Conclusion TBE is essential post myotomy, particularly if a substantial esophageal dilatation occurs pre-operatively (stage 3). Initial stage is associated with surgical outcomes, advanced stages being related to poorer emptying and more dilated esophagus after surgery. TBE is a reliable system to objectively define surgical outcomes and preserved esophageal function after Heller-Dor procedure. Disclosure All authors have declared no conflicts of interest.

BackgroundIntrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE.MethodsA retrospective analysis of all HRM (unweighted sample n = 155) performed at a tertiary referral center from 09/2015–03/2017 yielded a case group (n = 114) with abnormal AM-IBP and a control group (n = 41) with a normal AM-IBP (pressure < 17 mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 min or as tablet retention after 5 min.ResultsAM-IBP was significantly related to liquid barium retention (p = 0.003) and tablet arrest on timed barium esophagram (p = 0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p < 0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p = 0.002).ConclusionsOur findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.