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. 2020 Apr 30;26(2):204-214.
doi: 10.5056/jnm19135.

Role of Rapid Drink Challenge During Esophageal High-resolution Manometry in Predicting Outcome of Peroral Endoscopic Myotomy in Patients With Achalasia

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Free PMC article

Role of Rapid Drink Challenge During Esophageal High-resolution Manometry in Predicting Outcome of Peroral Endoscopic Myotomy in Patients With Achalasia

Hélène Foisy et al. J Neurogastroenterol Motil. .
Free PMC article

Abstract

Background/aims: Peroral endoscopy myotomy (POEM) is effective to treat achalasia. We aim to determine POEM effect on esophageal function and search for predictive factors of response to POEM and co-occurrence of gastroesophageal reflux disease (GERD).

Methods: A total of 64 untreated achalasia patients who underwent high-resolution manometry (HRM) before and 3 months after POEM were retrospectively included. Response to treatment was defined as an Eckardt score < 3. Reflux symptoms and patient's satisfaction were evaluated. Data were compared using paired t test, Chi-square test or log rank test.

Results: The 2-year success rate in response to POEM was 90%. All responders reported being satisfied while only 33% of non-responders did (P < 0.001) and 64% of patients with reflux symptoms were satisfied versus 96% of those without (P = 0.009). On HRM, the integrated relaxation pressure and the contractile pattern changed significantly after POEM but were not predictive of response. Between pre and post POEM HRM, a decrease in maximal esophageal pressurization during rapid drink challenge (RDC) was associated with a better response rate than an increase of pressurization (91% vs 50%, P = 0.004). As evidenced by pH monitoring performed after POEM, GERD was pathological or borderline in 50% of patients (18/36) while only 19% (11/59) reported clinically significant reflux symptoms. On post POEM HRM, maximal esophageal pressurization during RDC was lower in patients with pathological or borderline GERD compared to those without (P = 0.054).

Conclusions: Esophageal HRM parameters changed significantly after POEM. Maximal esophageal pressurization during RDC may be useful to predict outcome.

Keywords: Esophageal achalasia; Gastroesophageal reflux; Manometry; Myotomy.

Conflict of interest statement

Conflicts of interest: Sabine Roman: consulting for Medtronic and research grants from Crospon and Diversatek Healthcare; and François Mion: consulting for Medtronic, Laborie, Janssen, MSD, and Endostim.

Figures

Figure 1
Figure 1
Example of esophageal high-resolution manometry (HRM) before (A) and after (B) peroral endoscopic myotomy (POEM). Before POEM, HRM was typical of type II achalasia with impaired esophagogastric junction (EGJ) relaxation (integrated relaxation pressure [IRP] > 15 mmHg), absence of esophageal contraction and pan-esophageal pressurization. After POEM, a fragmented esophageal contraction is observed with a normalization of IRP (< 15 mmHg). The zone of myotomy is visible as a distal defect between the esophageal contraction and the EGJ. After the second swallow, pressurization is observed in the zone of the myotomy. The esophageal length is measured from the distal border of the upper esophageal sphincter (UES) to the proximal border of the EGJ defined at the 30-mmHg isobaric contour during a period without swallowing and at the end of the expiration (vertical arrows). The fragmented contraction might indicate an incomplete myotomy.
Figure 2
Figure 2
Patients’ flow chart. One hundred and ninety-six peroral endoscopic myotomies (POEM) were performed during the studied period and 64 patients with achalasia, without previous treatment, and with pre- and post-treatment high-resolution manometry (HRM) were included. Patients with incomplete data (catheter not passed through the esophagogastric junction (EGJ) or absent Eckardt score at 3 months) were excluded.
Figure 3
Figure 3
Post-treatment esophageal body contractility according to pretreatment achalasia subtypes. Esophageal contraction was absent in 80% of patients with type I achalasia treated with peroral endoscopic myotomy (POEM). Esophageal contractility (intact, ineffective, fragmented, or premature) was present in most patients with type II, type III or incomplete form of achalasia (89%, 88%, and 100%).
Figure 4
Figure 4
Response to treatment is presented at 3 months and during the last follow-up visit (median duration after peroral endoscopic myotomy [POEM]: 21 months [range 3.4-57.3]). Five patients with a negative response at 3 months were persistent non-responders at the last followup visit; 1 had myositis, 1 underwent second POEM, 14 months after the first one, and 3 did not receive any further treatment. Five patients with a positive response at 3 months presented recurrent symptoms at the last follow-up visit: 1 underwent a second POEM, 18 months after the first one, and 4 did not receive any further treatment. *One myositis: 1 second POEM at 14 months; 3 follow-up without treatment. **One second POEM at 18 months; 4 follow-up without re-treatment.
Figure 5
Figure 5
Positive response rate after peroral endoscopic myotomy procedure according to the Kaplan-Meier survival curve. At 12 months, the success rate was 92% for 53 patients at risk. At 24 months the success rate was 90% for 27 patients at risk.

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