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An Improved Method of Assessing Esophageal Emptying Using the Timed Barium Study Following Surgical Myotomy for Achalasia
Arzu Oezcelik*1, Jeffrey a. Hagen1, James M. Halls2, Jessica M. Leers1, Emmanuele Abate1, Shahin Ayazi1, John C. Lipham1, Farzaneh Banki1, Steven R. Demeester1, Tom R. Demeester1
1Surgery, Keck School of Medicine, University of Southern California, Los Angeles/, CA; 2Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
Introduction: The timed barium study is a test used to quantitatively assess esophageal emptying in patients with achalasia by measuring the percent difference in area of the barium column on films obtained 1 and 5 minutes after ingesting 150 ml of barium. Improvement in emptying on the timed barium study has been documented after endoscopic therapy. After surgical myotomy, the improvement in esophageal emptying reported has been variable. Many patients following myotomy who have little change in emptying as traditionally measured have improved clearance of the barium before the 1 minute film is taken. The aim of this study was to evaluate a new method for assessing improvement in esophageal emptying after therapy in patients with achalasia.
Methods: A standard timed barium study was performed before and 3-6 months after a myotomy for achalasia in 30 patients. Esophageal emptying was assessed by comparing the area of the residual barium column on digital images obtained 1 and 5 minutes after ingestion of 150 ml of barium. Improvement in emptying was determined by comparing the results before and after therapy. We also assessed improvement after therapy by comparing the area of the barium column on the 1 minute images obtained before and after therapy, which we defined as initial esophageal clearance. Both measures of improvement were compared to clinical outcome.
Results: On clinical follow up, 21 (70%) patients had no symptoms, 4 (13%) had minimal symptoms, and 5 (17 %) had moderate/severe symptoms. When calculated using the traditional method, esophageal emptying before and after surgery were not significantly different (25% vs. 37%; p>0.05) and did not correlate with clinical outcome. However, when improvement in emptying was assessed by comparing clearance, the median improvement comparing the 1 minute films before and after therapy was 81 %. Improvement in clearance correlated significantly with clinical outcome (Table). All patients with esophageal clearance less than 40% had moderate or severe symptoms.
Conclusion: Esophageal emptying measured by the timed barium study calculated by the traditional method is not useful to assess outcome after surgical myotomy. We have described a new method for calculating esophageal clearance that correlates well with clinical outcome after surgical therapy.
| No symptoms | Minimal Symptoms | Moderate/Severe Symptoms | Kruskal-Wallis p-value | |
| Traditional Method (Ratio of pre- vs. post-therapy) | 0.7 (0.2-1.6) | 0.4 (0.2-2.7) | 0.9 (0.6-1.8) | p=0.78 |
| Initial Esophageal Clearance (Percent improvement) | 89 (77-98) | 89 (77-98) | 44 (28-48) | p< 0.0002 |
Value are shown as median (IQR)
