Esophagogastric Junction Metrics Research Articles

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.

772. EVALUATING OUTCOMES OF LES OBSTRUCTION AND REFLUX IN PATIENTS UNDERGOING PERORAL ENDOSCOPIC MYOTOMY GUIDED BY THE 16CM IMPEDANCE PLANIMETRY CATHETER

Abstract Background Peroral endoscopic myotomy (POEM) is a standard treatment option in achalasia. The endoluminal functional lumen imaging probe (FLIP) system utilizes impedance planimetry to measure diameter and distensibility at the esophagogastric junction (EGJ) in real-time. Most reports of the intraoperative FLIP experience focus on the 8 cm balloon, but the 16 cm balloon catheter also provides topographical assessments in addition to EGJ metrics. The aim of this study is to determine the clinical outcomes after a tailored myotomy using the 16 cm balloon during POEM. Methods We conducted a retrospective review of consecutive patients who underwent POEM with intraoperative FLIP with the 16 cm balloon catheter between January 2020 and September 2023. Operative reports were reviewed, and data including FLIP metrics and topographical assessments and myotomy length, which was guided by FLIP panometry, were recorded. Clinical parameters for lower esophageal sphincter (LES) obstruction (defined by FLIP-EGJ metrics, BEDQ/Eckardt scores and/or need for LES re-intervention) and reflux (defined by GERD-HRQL/RSI scores, +pH testing, LA B/C/D reflux esophagitis, PPI use and/or need for anti-reflux surgery) were collected during the 6-36 month follow up time period. Results Of 100 patients (57 female, mean 56.1y), 82 had Achalasia, 15 EGJOO, and 3 hypercontractile esophagus. Myotomy length was tailored (mean 8.2cm, range 3 – 15) by FLIP, and 10% had a short myotomy (≤4cm). Among 16 patients with previous Heller, the myotomy targeted contractile activity proximal to the previous myotomy in 10 cases. On follow up of 71 patients (median time 14mo), clinical outcomes are noted in Table 1. Obstructive symptoms and FLIP metrics showed significant improvement. Repeat myotomy was required in 5.6%. While reflux symptom scores improved, 37.5% had abnormal %AET, 4.7% had reflux esophagitis, and 7.0% required anti-reflux surgery. Conclusion A tailored myotomy with guidance of a 16 cm FLIP catheter to assess EGJ metrics and topographical assessments during POEM appears to be safe and effective at 6-36 month follow up. A tailored myotomy allows for a shorter myotomy than traditional surgical lengths and can be extended to capture residual disease noted with the 16 cm FLIP catheter in patients with previous surgery. Use of the 16 cm balloon during POEM results in overall low rates of LES re-intervention and post-myotomy reflux.

Transoral incisionless fundoplication with or without hiatal hernia repair for gastroesophageal reflux disease after peroral endoscopic myotomy.

Background and study aims Gastroesophageal reflux disease (GERD) following peroral endoscopic myotomy (POEM) occurs in 40% to 60% of patients. There are limited data evaluating antireflux surgery or transoral incisionless fundoplication (TIF) for refractory post-POEM GERD. Patients and methods In a single-center prospective cohort study, consecutive patients with medically refractory post-POEM regurgitation and/or GERD treated with TIF or combined laparoscopic hernia repair and TIF (cTIF) were evaluated. Baseline evaluation: GERD-Health Related Quality of Life (GERD-HQRL) and Reflux Symptom Questionnaire 7-day recall (RESQ-7) questionnaires, EGD, high-resolution manometry (HRM), 48-hour pH test off proton pump inhibitors (PPIs) and impedance planimetry of the esophagogastric junction (EGJ) to calculate the diameter distensibility index (EGJ-DI). A PPI was taken twice daily for 2 weeks after TIF and restarted later if required. Patients returned 9 to 12 months after treatment when all preoperative studies were repeated. Quality of life, pH studies and EGJ metrics before and after antireflux surgery were compared. Results Seventeen patients underwent TIF (n=2, 12%) or cTIF (n=15, 88%) a mean 25±15 months after POEM. At follow-up a mean of 9±1 months after TIF/cTIF, patients required less frequent daily PPIs (n=0.001), were more satisfied (P=0.008), had improved GERD-HQRL (P=0.001), less intensity and frequency of GERD (P=0.001) and fewer reflux episodes (P=0.04) by pH testing. There was no change in EGJ-DI, EGJ diameter, integrated relaxation pressure, % total time pH <4, or DeMeester score. Conclusions TIF and cTIF for difficult-to-control post-POEM GERD appear safe, decrease PPI use and reflux episodes, and improve QOL without significant change in IRP, EGJ compliance, diameter or esophageal acid exposure time.

Upper Esophageal Sphincter Metrics across Eosinophilic Esophagitis, Gastroesophageal Reflux Disease and Functional Dysphagia: A Pilot Study.

Recent studies have evaluated the upper esophageal sphincter (UES) with high-resolution manometry (HRM) in some esophageal diseases, but not eosinophilic esophagitis (EoE). The aim of our study was to evaluate the function of the UES across EoE, gastroesophageal reflux disease (GERD), functional dysphagia (FD), and the relationship with esophageal symptoms, esophageal body contraction, and esophagogastric junction (EGJ) metrics. HRM was performed on 30 EoE, 18 GERD, and 29 FD patients according to the Chicago Classification 3.0. The study data were exported to the online analysis platform Swallow Gateway. The UES was assessed in terms of UES Resting Pressure (UES-RP), UES Basal Pressure (UES-BP), UES Integrated Relaxation Pressure (UES-IRP), UES Relaxation Time (UES-RT), Basal UES Contractile Integral (Basal UES-CI), Post-Deglutitive UES Contractile Integral (Post-Deglutitive UES-CI), and Proximal Contractile Integral (PCI). ANOVA analysis showed significantly higher values of Post-Deglutitive UES-CI in EoE patients compared with FD patients (p = 0.001). Basal UES-CI and UES-RP showed significantly higher values in EoE (p = 0.002, p = 0.038) and GERD (p < 0.001, p = 0.001) patients compared with FD patients. Correlations between LES-CI and Post-Deglutitive UES-CI, Basal UES-CI, and UES-RP (p ≤ 0.001, p = 0.027, p = 0.017, respectively), and between LES-BP and Post-Deglutitive UES-CI (p = 0.019), independent of diagnosis, were shown. No correlations have been demonstrated between the UES, EGJ metrics, and esophageal symptoms. Some differences in UES metrics in the three different diseases were found. Further studies are needed to confirm the results of our pilot study and possible applications in clinical practice.

Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0©.

Chicago Classification v4.0 (CCv4.0) is the updated classification scheme for esophageal motility disorders using metrics from high-resolution manometry (HRM). Fifty-two diverse international experts separated into seven working subgroups utilized formal validated methodologies over two-years to develop CCv4.0. Key updates in CCv.4.0 consist of a more rigorous and expansive HRM protocol that incorporates supine and upright test positions as well as provocative testing, a refined definition of esophagogastric junction (EGJ) outflow obstruction (EGJOO), more stringent diagnostic criteria for ineffective esophageal motility and description of baseline EGJ metrics. Further, the CCv4.0 sought to define motility disorder diagnoses as conclusive and inconclusive based on associated symptoms, and findings on provocative testing as well as supportive testing with barium esophagram with tablet and/or functional lumen imaging probe. These changes attempt to minimize ambiguity in prior iterations of Chicago Classification and provide more standardized and rigorous criteria for patterns of disorders of peristalsis and obstruction at the EGJ.

High-resolution Manometry Determinants of Refractoriness of Reflux Symptoms to Proton Pump Inhibitor Therapy.

Background/AimsImpaired esophageal motility and disrupted esophagogastric junction (EGJ) on high-resolution manometry (HRM) have been associated with increased reflux severity in gastroesophageal reflux disease (GERD) patients. However, there are limited data evaluating HRM parameters in proton pump inhibitors (PPI) non-responders.MethodsClinical and endoscopic data, HRM and multichannel intraluminal impedance-pH studies performed of PPI therapy in patients with typical GERD symptoms were reviewed from 3 international centers. Frequency of GERD symptoms was assessed on and off PPI therapy in both non-responders (< 50% symptom improvement on PPI therapy) and responders. Rome IV definitions identified non-erosive reflux disease, reflux hypersensitivity, and functional heartburn. Univariate and multivariate analyses were performed to determine predictors of non-response.ResultsOf 204 patients, 105 were PPI non-responders and 99 were responders. Non-responders showed higher EGJ contractile integral values, and a lower frequency of type II and III EGJ morphology (P ≤ 0.03 for each comparison). Esophageal body diagnoses on HRM (fragmented peristalsis, ineffective esophageal motility, or absent peristalsis) did not predict non-response. On multivariate analysis, non-pathological acid exposure time (OR, 2.5; 95% CI, 1.2-5.0; P < 0.001), normal mean nocturnal baseline impedance values (OR, 2.7-2.4; 95% CI, 1.0-6.1; P < 0.05), normal EGJ contractile integral values (OR, 3; 95% CI, 1.3-7.4; P = 0.012), and presence of type I EGJ morphology (OR, 1.9; 95% CI, 1.0-3.4; P = 0.044) were associated with an unfavorable response to PPIs.ConclusionsIntact EGJ metrics on HRM complement normal reflux burden in predicting non-response to PPI therapy. HRM has value in the evaluation of PPI non-responders.

Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia-Anatomy Matters!

To compare the utility of the distensibility index (DI) on functional lumen imaging probe (FLIP) topography to other esophagogastric junction (EGJ) metrics in assessing treatment response in achalasia in the context of esophageal anatomy. We prospectively evaluated 79 patients (at ages 17-81 years; 47% female patients) with achalasia during follow-up after pneumatic dilation, Heller myotomy, or per-oral endoscopic myotomy with timed barium esophagram, high-resolution impedance manometry, and FLIP. Anatomic deformities were identified based on consensus expert opinion. Patients were classified based on anatomy and EGJ opening to determine the association with radiographic outcome and Eckardt score (ES). Twenty-seven patients (34.1%) had an anatomic deformity-10 pseudodiverticula at myotomy, 7 epiphrenic diverticula, 5 sigmoid, and 5 sinktrap. A 5-minute column area of >5 cm was best associated with an ES of >3, with a sensitivity of 84% (P = 0.0013). Area under the curve for EGJ metrics in association with retention was as follows: DI, 0.90; maximal EGJ diameter, 0.76; integrated relaxation pressure, 0.64; and basal esophagogastric junction pressure, 0.53. Only FLIP metrics were associated with retention given normal anatomy (DI 2.4 vs 5.2 mm/mm Hg and maximal EGJ diameter 13.1 vs 16.6 mm in patients with and without retention, respectively; P values < 0.0001 and 0.002). Using a DI cutoff of <2.8 as abnormal, 40 of 45 patients with retention (P = 0.0001) and 23 of 25 patients with an ES of >3 (P = 0.02) had a low DI and/or anatomic deformity. With normal anatomy, 21 of 22 patients with retention had a low or borderline low DI. The FLIP DI is most useful metric for assessing the effect of achalasia treatment on EGJ opening. However, abnormal anatomy is an important mediator of outcome and treatment success will be modulated by anatomic defects that impede bolus emptying.

Correlation between novel 3D high-resolution manometry esophagogastric junction metrics and pH-metry in reflux disease patients.

We recently developed 2 novel 3D high-resolution manometry (HRM) metrics of esophagogastric junction (EGJ) contractility to differentiate the lower esophageal sphincter (LES) and crural diaphragm (CD) elements of EGJ pressure. This study aimed to compare these metrics to the EGJ-contractile integral (EGJ-CI) and to analyze their correlation with esophageal acid exposure time (AET) on pH-metry. Thirty-one gastro-oesophageal reflux disease (GERD) patients and 20 control subjects underwent 24-hour pH-metry and HRM using a 3D-HRM catheter. EGJ metrics were calculated during 3 consecutive respiratory cycles at rest. The EGJ-CI was calculated using the DCI tool in the ManoView software. 3D LES pressure (3D-LESP) and 3D-DHA, a metric quantifying the CD component of the 3D-HRM pressure topography, were calculated using a MATLAB program. Pearson correlation was used to calculate correlations with AET. 3D-LESP, 3D-DHA, and EGJ-CI were all significantly lower in GERD patients than in control subjects (P<.05) and all were significantly correlated with AET (R=-.48, -.42, -.52, respectively, all P<.01). The 3D-DHA and EGJ-CI also strongly correlated with each other (R=.84, P<.001). Both 3D-EGJ metrics were correlated with AET emphasizing the importance of both LES and CD function as a determinant of EGJ competence. 3D-DHA also strongly correlated with the EGJ-CI suggesting that EGJ-CI is strongly driven by the asymmetrical CD pressure component.

Novel 3D high-resolution manometry metrics for quantifying esophagogastric junction contractility.

The esophagogastric junction (EGJ) is a complex sphincter composed of both the crural diaphragm (CD) and lower esophageal sphincter (LES). Three dimensional high-resolution manometry (3D-HRM) provides a dynamic 360° representation of EGJ pressure in which the CD has a distinct pressure signature. We aimed to develop 3D-HRM metrics to: (i) quantify the vigor of CD contractility, (ii) best eliminate the CD contribution and thereby isolate the LES component of EGJ contractility, and (iii) compare these metrics with conventional HRM metric of EGJ contractility. Twenty healthy subjects underwent 3D-HRM studies. Two novel 3D-HRM EGJ metrics, 3D-DHA , and 3D-LES pressure (3D-LESP) were devised and calculated to best approximate the CD and LES components of the composite EGJ pressure topography. These values were then compared to conventional HRM metrics of EGJ contractility, the EGJ contractile integral (EGJ-CI), inspiratory EGJ pressure and expiratory EGJ pressure. Mean 3D-DHA correlated most strongly with EGJ-CI (r=.82, P<.001), while the 3D-LESP correlated most strongly with inspiratory EGJ pressure (r=.91 P<.001) and expiratory EGJ pressure (r=.85, P<.001). We devised novel 3D-HRM metrics to quantify the CD (3D-DHA ) and LES (3D-LESP) elements of EGJ contractility. Both measures correlated strongly with conventional HRM metrics of EGJ contractility. The 3D-DHA , in particular, correlated strongly with the EGJ-CI suggesting that both are largely determined by CD contractility. It is hoped that future studies will show these new metrics useful in quantifying elements of the antireflux barrier in mechanistically defined subsets of gastro-esophageal reflux disease (GERD) patients.

Sa1351 Baseline Esophagogastric Junction Metrics and Dynamic Esophageal Body Contraction Changes on Provocative Testing Differentiate Etiologies of Esophagogastric Junction Outflow Obstruction (EGJOO)

Sa1351 Baseline Esophagogastric Junction Metrics and Dynamic Esophageal Body Contraction Changes on Provocative Testing Differentiate Etiologies of Esophagogastric Junction Outflow Obstruction (EGJOO)

Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease

Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM. Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM. Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08). Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS.