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Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study

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Abstract

Background

Peroral endoscopic myotomy (POEM) has been introduced as an endoscopic alternative to surgical myotomy. The endoluminal functional lumen imaging probe (endoFLIP) evaluates esophagogastric junction (EGJ) distensibility based on cross-sectional area and pressure in response to volume distension. The aim of this study was to evaluate whether there is a correlation between endoFLIP measurements during POEM and postoperative clinical outcomes in terms of symptom relief and development of post-procedure reflux.

Methods

We conducted a retrospective review of achalasia patients who underwent POEM and intraoperative endoFLIP at three tertiary centers. Patients were divided into two groups based on clinical response measured by Eckardt score (ES): good response (ES < 3) or poor response (ES ≥ 3). Post-procedure reflux was defined as the presence of esophagitis and/or abnormal pH study. EGJ diameter, cross-sectional area, and distensibility measured by endoFLIP were compared.

Results

Of the 63 treated patients, 50 had good and 13 had poor clinical response. The intraoperative final EGJ cross-sectional area was significantly higher in the good-response group versus poor-response group; median (interquartile range): 89.0 (78.5–106.7) versus 72.4 (48.8–80.0) mm2 [p = 0.01]. The final EGJ cross-sectional area was also significantly higher in patients who had reflux esophagitis after POEM: 99.5 (91.2–103.7) versus 79.3 (57.1–94.2) mm2 [p = 0.02].

Conclusion

Intraoperative EGJ cross-sectional area during POEM for achalasia correlated with clinical response and post-procedure reflux. Impedance planimetry is a potentially important tool to guide the extent and adequacy of myotomy during POEM.

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Abbreviations

CSA:

Cross-sectional areas

ES:

Eckardt score

endoFLIP:

Endoluminal functional lumen imaging probe

EGJ:

Esophagogastric junction

IQR:

Interquartile range

IRP:

Integrated relaxation pressure

LES:

Lower esophageal sphincter

POEM:

Peroral endoscopic myotomy

SD:

Standard deviation

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Authors and Affiliations

  1. Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MD, USA

    Saowanee Ngamruengphong, Vivek Kumbhari, Mohamad El Zein, Ahmed Abdelgelil, Sepideh Besharati, John O. Clarke, Ellen M. Stein, Anthony N. Kalloo & Mouen A. Khashab

  2. Department of General Surgery, University Hospital Wurzburg, Würzburg, Germany

    Burkhard H. A. von Rahden & Jörg Filser

  3. Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY, USA

    Amy Tyberg, Amit Desai, Reem Z. Sharaiha, Arnon Lambroza & Michel Kahaleh

  4. Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA

    Mouen A. Khashab

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  1. Saowanee Ngamruengphong
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Correspondence to Mouen A. Khashab.

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Disclosures

Mouen A. Khashab is a consultant for Boston Scientific, Olympus America, and Xlumena. Michel Kahaleh is a consultant for Boston Scientific and Xlumena and has done research for Gore, MI Tech, and Pinnacle. He has done research and consulting for Mauna Kea Technologies. Anthony N. Kalloo is a founding member, equity Holder, and consultant for Apollo Endosurgery. Burkhard H. A. von Rahden received travel grants by Karl Storz GmbH Tuttlingen for establishing the POEM procedure in Wuerzburg. Furthermore, POEM procedure with KARL STORZ GmbH equipment was funded by the company. Saowanee Ngamruengphong, Jörg Filser, Amy Tyberg, Amit Desai, Reem Z. Sharaiha, Arnon Lambroza, Vivek Kumbhari, Mohamad El Zein, Ahmed Abdelgelil, Sepideh Besharati, John O. Clarke, and Ellen M. Stein have no conflict of interest or financial ties to disclose.

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Ngamruengphong, S., von Rahden, B.H.A., Filser, J. et al. Intraoperative measurement of esophagogastric junction cross-sectional area by impedance planimetry correlates with clinical outcomes of peroral endoscopic myotomy for achalasia: a multicenter study. Surg Endosc 30, 2886–2894 (2016). https://doi.org/10.1007/s00464-015-4574-2

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