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EVALUATION OF ESOPHAGOGASTRIC JUNCTION DISTENSIBILITY CHANGES FOLLOWING SURGICAL MYOTOMY FOR ACHALASIA
Ryan J. Campagna*1, Ezra N. Teitelbaum1, Joel M. Sternbach1, Dustin Carlson2, Peter J. Kahrilas2, John E. Pandolfino2, Nathaniel J. Soper1, Eric S. Hungness1
1Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; 2Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
Introduction
The functional lumen imaging probe (FLIP) is a novel catheter-based device that measures esophagogastric junction (EGJ) distensibility index (DI) in real-time. Previous studies have demonstrated DI to be a strong predictor of post-treatment clinical recurrence in patients with achalasia. We sought to evaluate perioperative DI changes in patients with achalasia undergoing per-oral esophageal myotomy (POEM) or laparoscopic Heller myotomy (LHM) and to assess the correlation of DI with postoperative outcomes.
Methods
DI (defined as the minimum cross-sectional area at the EGJ divided by distensive pressure) was measured at four time points in patients undergoing surgical myotomy for achalasia: 1) during outpatient preoperative endoscopy (preop DI), 2) at the start of each operation after the induction of anesthesia (induction DI), 3) at the conclusion of each operation (post-myotomy DI), and 4) at routine follow-up endoscopy 6-24 months postoperatively (follow-up DI). Routine Eckardt symptom score, endoscopy, timed barium esophagram, and pH study were obtained 6-24 months postoperatively.
Results
Forty-six patients were included (35 POEM, 11 LHM). For POEM patients, preop and induction mean DI were similar (1 vs. 0.9 mm2/mmHg). The POEM procedure resulted in a 7-fold increase in DI (induction 0.9 vs. post-myotomy 7 mm2/mmHg, p<0.001). There was a subsequent decrease in DI in the follow-up period (post-myotomy 7 vs. follow-up 4.8 mm2/mmHg, p<0.01), but DI at follow-up was still significantly improved from preop (p<0.001). For LHM patients, DI was also similar at preop and induction, and increased as a result of surgery (induction 1.5 vs. post-myotomy 5.9 vs mm2/mmHg, p<0.001). Comparing cohorts, POEM resulted in a larger increase in DI than LHM (DI increase 6.2 vs. 4.4 mm2/mmHg, p<0.05). After LHM, DI also decreased in the follow-up period, but this change was not statistically significant (5.9 vs. 4.4 mm2/mmHg, p=0.29). Eckardt symptoms scores (scale 0-12) at median 12 month follow-up showed similar improvement as a result of POEM and LHM (POEM: 7 vs. 2, LHM: 7 vs. 2; both p<0.001). LHM patients with erosive esophagitis on follow-up endoscopy had a significantly higher post-myotomy DI compared to those without esophagitis (9.3 vs 4.8 mm2/mmHg, p<0.05). There were no differences in post-myotomy DI between patients with or without barium retention on esophagram or an abnormal pH study in either cohort.
Conclusions
EGJ DI improved dramatically as a result of both POEM and LHM, with POEM resulting in a larger increase. Mean DI decreased at intermediate follow-up, but remained well above previously established thresholds for symptom recurrence. DI at the conclusion of LHM was predictive of erosive esophagitis in the postoperative period, which supports the potential use of FLIP for calibration of partial fundoplication construction during LHM.
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