Esophagogastric Junction Outflow Obstruction Research Articles

Esophageal Motility Disorders: A Concise Review on Classification, Diagnosis, and Management.

Esophageal motility disorders (EMDs) are an underrecognized cause of dysphagia and encompass a breadth of conditions, including achalasia, esophagogastric junction outflow obstruction, absent contractility, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility. Whereas patients with EMDs classically present with dysphagia to both solids and liquids, other symptoms such as heartburn, noncardiac chest pain, and regurgitation may also be present. The advent and standardization of high-resolution esophageal manometry by the Chicago Classification have revolutionized the diagnosis and management of EMDs. The EMDs are broadly classified into disorders of the esophagogastric junction (achalasia, esophagogastric junction outflow obstruction) and peristalsis (absent contractility, distal esophageal spasm, hypercontractile esophagus, ineffective esophageal motility). Additional tests, such as timed barium esophagogram and EndoFLIP, can help provide adjunctive information in cases in which high-resolution esophageal manometry findings are inconclusive. Management varies widely according to the type of EMD and can range from lifestyle and dietary modifications to oral pharmacologic therapy and various endoscopic or surgical interventions. In patients with achalasia, durable management aimed at the lower esophageal sphincter should strongly be considered. This clinical review aims to provide a concise yet comprehensive summary on classification, diagnosis, and management of EMDs.

Clinical characteristics and esophageal motility in patients with gastric cardia submucosal tumors and associated changes after endoscopic resection.

This study aimed to investigate the clinical characteristics and esophageal motility of patients with gastric cardia submucosal tumors (SMTs) and the associated changes after endoscopic resection based on high-resolution impedance manometry (HRIM). From our electronic database, we identified patients who underwent pre-operative evaluation of gastric cardia SMTs between 2015 and 2023. All patients completed standardized symptom questionnaires and underwent endoscopic ultrasonography and HRIM. Endoscopic resection via submucosal dissection or submucosal tunnel endoscopic resection was performed, followed by esophagogastroduodenoscopy and HRIM three months later. Esophageal motility on HRIM was compared based on the updated Chicago Classification v4.0. Thirty patients (mean age, 47.4 ± 12.8years; male, 50%) were analyzed. Most patients were asymptomatic (43.3%), while others presented with epigastralgia, regurgitation, chest pain, or dysphagia. On endoscopic ultrasonography, the average tumor size was 16.7 ± 4.5mm (range, 10.0-30.0mm), and most tumors originated from the fourth layer (80%). On HRIM, eight patients (26.7%) had abnormal esophageal motility, including five with ineffective esophageal motility (IEM) and three with esophagogastric junction outflow obstruction. Complete resection was achieved in 25 of the 27 patients (92.6%) who underwent endoscopic treatment. Pathology revealed leiomyomas (96%) and gastrointestinal stromal tumors (4%). No significant differences in symptom profiles or HRIM parameters were observed after tumor resection. Three patients with pre-operative IEM exhibited normal motility at the follow-up HRIM. Up to 26.7% of patients with gastric cardia SMTs had abnormal esophageal motility on HRIM. Endoscopic resection of these SMTs was effective and safe and appeared to improve esophageal motility in patients with IEM.

Obesity Impacts the Likelihood of Symptom Resolution in Patients with Esophagogastric Junction Outflow Obstruction.

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterised by an elevated integrated relaxation pressure (IRP) with preserved peristalsis. Most functional EGJOO symptoms are self-limiting. This study aimed to evaluate the risk factors associated with non-resolution of symptoms for functional EGJOO. A retrospective single institution cohort study was performed on patients diagnosed with functional EGJOO on high-resolution manometry (HRM). Clinical, demographic, endoscopic and imaging parameters were recorded. Univariate and multivariate analyses were performed to identify factors associated with reduced likelihood of symptom resolution. Time to symptom resolution was then plotted on a Kaplan-Meier survival analysis. Over a 5-year period, 53 patients (41.5% male, 58.5% female) were diagnosed with functional EGJOO. The median age, body mass index and IRP at 4s were 47.0years (interquartile range (IQR): 36.0-58.0), 23.3kg/m2 (IQR: 20.9-26.5) and 39.9mmHg (IQR: 28.6-52.3) respectively. Dysphagia and atypical chest pain accounted for 36.5% and 21.2% of symptoms respectively. On the univariate analysis, obesity (p = 0.002), heartburn (p = 0.098) and lack of epigastric pain (p = 0.090) were potentially correlated with failure of symptom resolution. In the multivariate analysis, only obesity (OR 0.11, 95% CI: 0.02-0.77; p = 0.026) was significantly associated with reduced likelihood of symptom resolution for EGJOO. On the survival analysis, 87.2% of non-obese patients, in contrast 37.5% of obese patients reported symptom resolution at up to 41-month follow-up period (p = 0.039). Patients with obesity are at an increased likelihood of having persistent symptoms. This association appeared to persist for patients with both manometric and clinically relevant EGJOO.

High prevalence of esophageal motility disorders in patients with rheumatologic diseases.

While it is commonly known that patients with rheumatologic diseases can have esophageal dysfunction, this association is insufficiently understood. The aim is to determine the prevalence and characteristics of esophageal motility disorders in patients with rheumatic diseases. This is a single-center retrospective study of adults with rheumatologic disease who underwent high-resolution esophageal manometry (HREM). Those with and without a motility disorder (defined per Chicago classification CCv3.0 criteria, given the timing of the prior studies) were compared and multivariable logistic regression was used to determine odds of motility disorder by rheumatic disease. Of 289 patients, the mean age was 60.5 ± 13.8years. Rheumatic diseases included Raynaud's (42%), rheumatoid arthritis (RA) (39%), Sjogren's (21%), systemic lupus erythematous (19%), systemic sclerosis (17%), and mixed connective tissue disease (13%). On HREM, 58% had an esophageal motility disorder: achalasia (5%), EGJ outflow obstruction (20%), jackhammer (8%), diffuse esophageal spasm (1%), ineffective esophageal motility (28%), and fragmented peristalsis (2%). Of note, 50% of the sample with a normal barium swallow had an esophageal dysmotility disorder on HREM. Those with psoriatic arthritis were less likely to have esophageal dysmotility (73% vs. 27%; P = 0.04). There was decreased odds of esophageal hypocontractility in those with RA (OR [95%CI]: 0.27 [0.12-0.58]) and increased odds (OR [95%CI]: 3.13 [1.16-8.41]) of esophageal hypocontractility among those with scleroderma. Esophageal motor disorders were found in more than half of patients with rheumatologic diseases who underwent HREM. HREM should be considered in patients with rheumatic conditions presenting with esophageal symptoms.

Additional Diagnostic Yield of the Rapid Drink Challenge in Chicago Classification Version 4.0 Compared With Version 3.0.

Chicago classification version 4.0 enhances the diagnosis of esophageal motility disorders using position change and provocative tests such as multiple rapid swallows and a rapid drink challenge. This study investigates the diagnostic role of the rapid drink challenge based on Chicago classification 4.0 using a functional luminal imaging probe to estimate the cutoff value. This study included 570 patients who underwent esophageal manometry with a rapid drink challenge between January 2019 and October 2022. The diagnostic flow was analyzed according to Chicago classification 4.0. Ninety-nine patients (38, achalasia; 11, esophagogastric junction outflow obstruction; 7, ineffective esophageal motility; 1, hypercontractile esophagus; and 42, normal esophageal function) failed the rapid drink challenge. Among the 453 participants, 50 and 86 were diagnosed with achalasia and esophagogastric junction outflow obstruction, respectively, using Chicago classification 4.0. In 249/453 (55.0%) patients initially diagnosed with esophagogastric junction outflow obstruction using Chicago classification 3.0, the diagnosis was changed to achalasia (n = 28), hypercontractile esophagus (n = 7), ineffective esophageal motility (n = 7), or normal esophageal function (n = 121) using Chicago classification 4.0. Rapid drink challenge-integrated relaxation pressure's diagnostic cutoff value was 19 mmHg. Nine patients had diagnoses changed after the rapid drink challenge, including 3 with panesophageal pressurization. Chicago classification 4.0 increased the diagnostic yield of the rapid drink challenge by 2.0% (9/453 patients). However, the rapid drink challenge had a failure rate of 17.9% (99/552 patients). Given the relatively low diagnostic yield and high failure rate of the rapid drink challenge, we recommend adopting an individualized approach to manometry.

Laparoscopic transhiatal surgery based on high-resolution manometric evaluation of epiphrenic esophageal diverticulum.

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6mmHg (> 26mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

Four-Dimensional Impedance Manometry in Esophageal Motility Disorders.

Four-dimensional high-resolution impedance manometry (4D HRM) uses impedance to estimate esophageal luminal cross-sectional area and track nadir impedance to measure intrabolus pressure (IBP). We aimed to determine whether 4D HRM metrics could define abnormal esophagogastric junction (EGJ) opening between Chicago Classification version 4.0 motility disorders and compare 4D HRM with functional lumen imaging probe (FLIP) metrics. Symptomatic adult patients who completed high-resolution impedance manometry and FLIP were included and compared with an asymptomatic control group. 4D HRM analysis used custom-built software to measure IBP, maximum EGJ diameter, and distensibility index on supine test swallows. 4D HRM metrics were compared with FLIP EGJ metrics. Ninety patients (31 normal motility, 16 ineffective esophageal manometry, 9 absent contractility, 8 conclusive EGJ outflow obstruction [EGJOO], 12 type I achalasia, 14 type II achalasia, 12 type III achalasia, and 34 asymptomatic controls) were included. Phase 2 and 3 IBP was higher in type II and III achalasia compared with controls and normal motility groups ( P < 0.03). Maximum EGJ diameter and EGJ-distensibility index in the conclusive EGJOO and achalasia groups were significantly lower than in controls and normal motility groups ( P < 0.03). 4D HRM identified 37 of 44 (84%) subjects with normal EGJ opening and 29 of 39 (74%) subjects with reduced EGJ opening on FLIP. 4D HRM metrics correlated with expected clinical observations across a spectrum of esophageal motility disorders and defined EGJ obstruction. 4D HRM metrics may have value in defining EGJ obstruction in equivocal cases related to EGJOO or absent peristalsis.

Botulinum toxin injection of the lower esophageal sphincter to identify achalasia-variant esophagogastric junction outflow obstruction.

Esophagogastric junction outflow obstruction (EGJOO) can be an achalasia variant caused by neuromuscular dysfunction of the lower esophageal sphincter (LES), or the manometric manifestation of mechanical processes that impair EGJ distensibility. Distinction among these conditions has important implications for treatment, but can be difficult. We hypothesized that response to botulinum toxin (BT) injection of the LES could be a diagnostic test for identifying achalasia-variant EGJOO likely to respond to LES muscle-directed invasive therapy. We reviewed our experience with symptomatic EGJOO patients who had BT injection of the LES. Data collected include demographics, esophageal body manometry findings, esophagram evidence of retention, and symptom response at 1-6months after BT injection categorized as poor, partial, or good. Clinical response to any subsequent LES-directed invasive treatment (EsoFLIP dilation, pneumatic dilation, Heller myotomy, or POEM) also was recorded. Thirteen symptomatic EGJOO patients were included (mean age 55.9 ± 16.4years; eight men, five women). Symptom response to BT injection was good in six (46%), partial in three (23%), and poor in three (23%); one was lost to follow-up. All five patients who received invasive treatment after partial or good response to BT had a partial or good response to invasive treatment. The one patient who had invasive treatment after a poor response to BT had a poor response to invasive treatment. These findings suggest that a good response to BT injection of the LES can identify an achalasia-variant form of EGJOO that will respond to LES muscle-directed invasive therapy.

Distal contractile integral and other key predictors of mean nocturnal baseline impedance: The role of esophageal peristaltic vigor in mucosal permeability.

Understanding the relationship between distal contractile integral (DCI) and mean nocturnal baseline impedance (MNBI) could shed light on new diagnostic and treatment strategies, specifically concerning nocturnal reflux. This study aimed to assess this relationship to enhance our comprehension of the interplay between esophageal contractility and mucosal permeability. We identified adult patients who had high resolution esophageal manometry and pH-impedance tests performed within a 30-day period between December 2018 and March 2022. A random forest model was used to identify significant predictors of MNBI, assisting with variable selection for a following regression analysis. Subsequently, both univariable and multivariable regression models were utilized to measure the association between predictors and MNBI. Our study included 188 patients, primarily referred for testing due to reflux. The most common motility diagnoses were normal (62%) followed by possible esophagogastric junction outflow obstruction (22%). The mean DCI was 2020 mmHg∙s∙cm and MNBI was 3.05 kΩ. The random forest model identified 12 significant predictors for MNBI, key variables being acid exposure time (AET), total proximal reflux events, intraabdominal lower esophageal sphincter length, hiatal hernia presence, and DCI. Subsequent multivariable regression analyses demonstrated log AET (β = -0.69, p = <0.001), total proximal reflux events (β = -0.16, p = 0.008), hiatal hernia presence (β = -0.82, p = 0.014), log DCI (β = 1.26, p < 0.001), and age (β = -0.13, p = 0.036) as being significantly associated with MNBI. DCI is a key manometric predictor of MNBI emphasizing the role of manometry in detecting reflux risk and the need for its consideration in reflux management.

S675 Esophagogastric Junction Outflow Obstruction: An Investigation of Ancillary Diagnostics Among Patients Meeting Manometric Criteria

S675 Esophagogastric Junction Outflow Obstruction: An Investigation of Ancillary Diagnostics Among Patients Meeting Manometric Criteria

The history and use of the timed barium esophagram in achalasia, esophagogastric junction outflow obstruction, and esophageal strictures.

Dysphagia is one of the most common complaints that gastroenterologists encounter in the outpatient setting. To evaluate this common complaint, patients are often sent for a barium esophagram, a test that is widely available, inexpensive, and easy to perform. This simple test provides a reliable method to evaluate esophageal anatomy and structural abnormalities. This narrative reviews the history of the development and validation of the timed-barium esophagram (TBE), along with its strengths and limitations, and discusses its use in the pre- and posttreatment assessment of patients with achalasia, esophagogastric junction outflow obstruction (EGJOO), and esophageal strictures. Providing excellent anatomic detail of the esophagus and an accurate assessment of esophageal emptying, over time, the TBE has become part of the standard workup in our Swallowing Center for patients with dysphagia.

Esophagogastric Junction Outflow Obstruction or Something More? Unveiling Esophageal Neuroendocrine Carcinoma.

Esophagogastric Junction Outflow Obstruction or Something More? Unveiling Esophageal Neuroendocrine Carcinoma.

Normative high resolution esophageal manometry values in asymptomatic patients with obesity.

Surgical bariatric interventions, while highly effective, can be associated with post-operative esophageal symptoms, gastroesophageal reflux disease and esophageal dysmotility. Whether pre-operative physiology impacts this risk is unknown, in part because expected values on esophageal manometry in patients with obesity are not well understood. This study seeks to establish normative values on esophageal high resolution manometry (HRM) and the prevalence of esophageal dysmotility in the asymptomatic patient with obesity. This retrospective study included adult patients with body mass index (BMI) ≥35 kg m-2 without esophageal symptoms undergoing preoperative bariatric surgical evaluation, including HRM, at a single tertiary care center between February, 2019 and February, 2020. Of 104 asymptomatic patients with obesity, HRM identified normal esophageal motility in 94 (90.4%) with the remaining 10 having ineffective esophageal motility (3.8%), manometric esophagogastric junction outflow obstruction (3.8%), distal esophageal spasm (1.0%), and hypercontractile esophagus (1.0%). Mean of median lower esophageal sphincter integrated relaxation pressure (LES IRP) was 10.6 mmHg supine (95th percentile 21.5 mmHg) and 8.5 mmHg upright (95th percentile 21.3 mmHg). 86% of patients had intragastric pressure above 8 mmHg. Mean of mean distal contractile integral (DCI) was 2261.6 mmHg cm s-1 (95th percentile 5889.5 mmHg cm s-1). The vast majority of asymptomatic patients with obesity had normal manometry. LES IRP and DCI were higher than that observed in non-obese cohorts. Additionally, BMI correlated to increased intragastric pressure. These data suggest that normative values in patients with obesity should be adjusted to prevent overdiagnosis of EGJOO or hypercontractile esophagus.

371. ENDOFLIP: THE FUTURE OF DYSPHAGIA DIAGNOSIS AND MANAGEMENT

Abstract Background High-resolution manometry (HRM) is the gold standard for characterizing esophageal motility disorders, but it’s frequently associated with poor patient tolerance. A newer diagnostic tool, the Endoscopic Functional Lumen Imaging Probe (EndoFLIP), has emerged to assess esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis. Also, for motility disorders such as EGJ outflow obstruction (EGJOO), HRM-isolated features aren’t enough for the diagnosis. The diagnosis also requires symptom correlation and additional investigations like EndoFLIP. Methods We conducted a single-center prospective cohort study for patients with dysphagia and inconclusive or intolerant to HRM. The inclusion criteria were patients with an elevated median integrated relaxation pressure (IRP) on HRM and patients with an inconclusive or intolerant to HRM. Patients with isolated IRP on HRM were included, as this isolated finding does not allow for the definitive diagnosis of EGJOO. These patients underwent EndoFLIP testing from January 2022 to February 2024 at a tertiary center. Results We performed EndoFLIP on 42 patients (50% male; 50% female), 23,8% with EGJOO diagnosis on HRM, 21,4% with inconclusive HRM, and 54,8% patients intolerant to HRM. Twenty-three patients intolerant to HRM underwent EndoFLIP, enabling diagnosis in all cases. Four patients were diagnosed with EGJOO, 6 with achalasia, and 4 with ineffective esophageal motility (IEM). On 88% of patients, the EndoFLIP allowed a correct diagnosis and treatment, with 29% undergoing endoscopic treatment during the same procedure. 9 patients with inconclusive HRM were diagnosed after EndoFLIP: 3 were diagnosed with EGJOO, 4 with IEM, and 3 with achalasia. We report a significant discordance between EGJOO diagnosis on HRM and EndoFLIP results. 50% of patients diagnosed with EGJOO on HRM showed normal EndoFLIP results, with only 20% confirming the diagnosis, while 20% raised the possibility of the diagnosis being achalasia. 43,8% of patients diagnosed with EGJOO confirmed by EndoFLIP underwent endoscopic therapy with botulinum toxin or balloon dilation during the same procedure, resulting in clinical improvement for all patients. Discussion The discordance between HRM and EndoFLIP may arise from HRM's tendency to overdiagnose EJGOO, leading to unnecessary testing and treatments for EGJOO. Many EGJOO HRM diagnoses don't require therapy, as symptoms often resolve spontaneously or with dietary education, casting doubt on the isolated HRM finding's clinical significance. It's particularly beneficial for patients with inconclusive/intolerance to HRM, allowing correct diagnosis and treatment in cases of obstructive symptoms. These results support EndoFLIP as a screening tool for patients undergoing endoscopy, enabling better selection of those benefiting from subsequent HRM.

355. LONG-TERM RESULTS OF LAPAROSCOPIC HELLER-DOR FOR ESOPHAGO-GASTRIC JUNCTION OUTFLOW OBSTRUCTION: A PROSPECTIVE CONTROLLED TRIAL

Abstract Background The gold-standard treatment for esophago-gastric junction outflow obstruction (EGJOO) is still debated. Currently, the management of this motility disorder reflects the experience gained with esophageal achalasia, for which Laparoscopic Heller-Dor (LHD) has been proven to be an effective long-term treatment. However, prospective data comparing long-term results of LHD for these two motility disorders are still lacking. The aim of this prospective, controlled study was to assess the 5-year follow-up of laparoscopic Heller-Dor (LHD) in patients with EGJOO, compared with radiological stage I achalasia patients (ACH). Methods Patients with diagnosis of idiopathic EGJOO, referred for dysphagia or food regurgitation, and radiological stage I achalasia (subgrouped by manometric pattern I, II &amp; III), treated with LHD, were enrolled to the study and then followed prospectively for 5 years. During the follow-up patients were evaluated with Eckard score (ES), Barium-swallow X-ray, High Resolution Manometry (HRM), 24 hour pH-monitoring and Upper-Gastrointestinal endoscopy. The primary outcome was therapeutic success (presence of ES ≤3 or no additional treatment) at the 5-year follow-up assessment. The secondary outcomes included the postoperative IRP and the evidence of gastro-oesophageal reflux. Results The study involved 150 patients: 25 in the EGJOO group and 125 in the ACH group (25 pattern I, 74 pattern II, and 26 pattern III). The patients’ demographic and clinical parameters are summarized in Image. After 5 years, there was no significant difference in success rate: 92% in the EGJOO, 88% in achalasia pattern I, 91.9% in pattern II and 92.3% in pattern III (p=0.95). In the four groups, no differences were shown in the presence of postoperative esophagitis (p=0.08) and in the incidence of abnormal postoperative acid exposure (p=0.87) (Image). Conclusion This is the first long-term comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. After at least 5 years of follow-up, Laparoscopic Heller-Dor has a comparable success rate in both EGJOO and achalasia patients. Based on these data, we conclude that LHD can be proposed as a first-line treatment for symptomatic EGJOO, provided the diagnosis is accurate.

497. ENDOFLIP AND BOTULIN TOXIN INJECTION: THERAPEUTIC MANAGEMENT IN ESOPHAGEAL AND GASTRIC MOTILITY DISORDERS

Abstract Introduction Esophageal motility disorders present diagnostic and therapeutic challenges, with dysphagia being a common symptom prompting evaluation. The Endolumenal Functional Lumen Imaging Probe (EndoFLIP) has recently gained recognition as a valuable tool for assessing esophageal function. This study aims to evaluate the utility of EndoFLIP in guiding therapeutic interventions, specifically focusing on botulinum toxin injections, among patients presenting with diverse esophageal disorders. Moreover, the study acknowledges the potential of EndoFLIP as a diagnostic adjunct during diagnostic upper gastrointestinal endoscopy in cases where therapeutic alternatives are limited or as therapeutic trial. Methods A retrospective analysis was conducted on 21 patients who underwent EndoFLIP assessment and subsequently received botulinum toxin injection at the same procedure. These patients were identified from records at a tertiary center, covering the period from January 2022 to February 2023. EndoFLIP procedures were analyzed, focusing on patient symptoms and indication for the procedure. Data regarding clinical symptoms, EndoFLIP findings, and therapeutic interventions were extracted and analyzed to assess the role of EndoFLIP in guiding treatment decisions for esophageal disorders. The used cutoffs for esophagogastric junction (EGJ) distensibility index were &amp;lt; 2 mm2/mmHg and &amp;lt; 10 mm2/mmHg for pyloric distensibility. Results All patients referred for esophageal motility evaluation with EndoFLIP presented with dysphagia as the primary symptom. Two patients presented with postprandial bloating, leading to further evaluation with impedance planimetry to assess pyloric distensibility, suspected to be due to diabetic gastroparesis. Following EndoFLIP assessment, a conclusive diagnosis was achieved in all patients: 10 patients were diagnosed with esophagogastric junction outflow obstruction, 1 patient with absent contractility, 7 patients with achalasia, and 1 patient with hypercontractile esophagus. Patients who underwent planimetry to evaluate pyloric distensibility both exhibited reduced distensibility index. Following treatment, 10 patients showed clinical improvement and 11 await clinical reassessment. Conclusions Regarding the evaluation of the EGJ distensibility index in patients with achalasia without indication for invasive treatment, the EndoFLIP emerges as a diagnostic tool that allows for immediate guidance if intervention is recommended. Likewise, patients with refractory gastroparesis and pylorospasm identified through EndoFLIP may benefit from toxin injection for future myotomy decision. In conclusion, EndoFLIP serves as a valuable tool in diagnosing and guiding therapeutic interventions in patients with esophageal and gastric motility disorders. Further research is warranted to validate the role of EndoFLIP in optimizing treatment outcomes for esophageal disorders.

383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY

Abstract Introduction Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients. Methods Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI &amp;gt; 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance. Results 107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013). Discussion IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.

Efficacy and safety of per-oral endoscopic myotomy in non-achalasia esophageal motility disorders: a systematic review and meta-analysis.

Per‑oral endoscopic myotomy (POEM) is the preferred endoscopic modality for managing achalasia cardia. However, there are no recommendations on the role of POEM in non‑achalasia esophageal dysmotility disorders (NAEMD), including esophagogastric junction outflow obstruction (EGJOO), distal esophageal spasm (DES), and hypercontractile esophagus (HE). The present systematic review and meta-analysis aimed to assess the safety and efficacy of POEM in the treatment of NAEMD. MEDLINE, Embase, and Scopus were searched from inception to August 2023 for studies analyzing the outcome of POEM in NAEMD. Clinical success and adverse events were the main outcomes assessed. The event rates and their 95% confidence interval were calculated using a random effects model. A total of 11 studies with 271 patients were included in the final analysis. The pooled clinical success rate with POEM in NAEMD was 86.9% (82.9-90.9). On subgroup analysis, the pooled clinical success rates of POEM in DES and EGJOO were 97.8% (90.9-100.0) and 92.7% (86.3-95.1), which were significantly higher thanin HE 81.2% (73.5-88.8). Data from limited studies showed that the pooled rate of improvement in dysphagia and chest pain was 88.5% (83.0-93.9) and 87.4% (80.5-94.4). The pooled incidence of overall AEs and serious AEs was 12.6% (5.7-19.5) and 0.3% (0.0-1.9), respectively. On follow-up, the pooled incidence of new-onset heartburn was 18.7% (11.1-26.2). POEM is a safe and efficacious treatment modality for the management of NAEMD with a lower clinical success in patients with HE. Further large-scale studies are required to validate the findings of the present analysis.

Toll-Like Receptor 7-Expressed Macrophages Are Involved in the Pathogenesis of Esophageal Achalasia and Esophagogastric Junction Outflow Obstruction

Introduction: Esophageal achalasia is a typical esophageal motility disorder (EMD). Although viral infections have been hypothesized to play a role in the pathogenesis of esophageal achalasia, its etiology remains unclear. This study used esophageal muscle layer specimens collected during per-oral endoscopic myotomy (POEM) procedures to investigate the association between esophageal achalasia and esophagogastric junction outflow obstruction (EGJOO) and pattern recognition receptors. Methods: Patients with esophageal achalasia and EGJOO who underwent POEM were allocated to the EMD group. Biopsies of the inner circular muscle were conducted during the POEM procedure. The control group comprised individuals diagnosed with esophageal squamous cell carcinoma who underwent surgical resection. Expression of pattern recognition receptors, including Toll-like receptor (TLR) 7, was examined by polymerase chain reaction. Immunohistochemical staining was performed to determine TLR7 expression sites in the esophageal muscle layer, and the relationship between TLR7 mRNA expression and clinical score was investigated. Results: Our analysis revealed a notable upregulation of TLR7 mRNA levels within the muscle layer of esophageal achalasia and EGJOO, in contrast to those of control specimens. In contrast, the correlation between TLR7 and clinical score was not significant. Immunohistochemical staining revealed increased numbers of TLR7-expressing macrophages between the muscle layers. Conclusions: TLR7-expressing macrophages are involved in the innate immune response underlying esophageal achalasia and EGJOO. This result will lead to the elucidation of new pathogenetic mechanisms and the development of novel therapeutic targets.

Impaired esophagogastric junction relaxation and lung transplantation outcomes.

The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1years). The median IRP before and after LTx was 18.7 ± 3.8mmHg and 12 ± 5.6mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P =0.086), but CLAD-free survival (P =0.592) and rates of primary graft dysfunction (P =0.502) and acute cellular rejection (P =0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.