S680 Functional Luminal Imaging Probe (FLIP) Parameters Can Be Used to Classify Cause of Treatment Failure in Achalasia

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Introduction: Causes of myotomy failure in achalasia are variable and can be difficult to discern. Recent studies have shown that functional lumen imaging probe (FLIP) panometry is accurate in diagnosing esophagogastric junction (EGJ) obstruction after myotomy in achalasia. In this study, we examined whether FLIP can differentiate the specific cause of EGJ obstruction in cases of recurrent symptoms after myotomy. Methods: We performed a retrospective analysis of adult subjects referred to the Esophageal Clinic at our institution for indication of recurrent dysphagia after definitive achalasia therapy [laparoscopic Heller myotomy (LHM), per-oral endoscopic myotomy (POEM), or pneumatic dilation (PD)]. All subjects whom underwent esophagogastroduodenoscopy (EGD) with FLIP, high-resolution manometry (HRM), and barium esophagram were included. Data from these procedures were utilized to classify treatment failure causes by a multidisciplinary panel comprised of experienced gastroenterologists, cardiothoracic surgeons, and gastrointestinal surgeons as i) recurrent LES dysfunction, ii) EGJ obstruction which could be from the fundoplication or LES, iii) esophageal body dilatation/deformity, iv) peptic or other stricture, v), spastic muscular segment in esophageal body, or vi) not enough information/none of the above. One way ANOVA and unpaired 2-sided t-test were used for analyses. Results: Forty-two patients were included. Clinical data for the sample are shown in Table 1. The most common causes of recurrent symptoms were esophageal body dilation/deformity, followed by EGJ obstruction and recurrent LES dysfunction. EGJ opening in the setting of LES dysfunction was most impaired as measured by the DI (1.5 ± 1.6, vs 4.2 ± 1.5 in EGJ obstruction, vs 3.9 ± 2.1 in dilation/deformity, one-way ANOVA P = 0.007), max EGJ diameter (10.8mm ± 3.7, vs 14.6mm ± 3.3 in EGJ obstruction, vs 14.5mm ± 3.9 in dilation/deformity, one-way ANOVA P = .055), and maximal pressure (61.9 mmHg ± 16.9, vs 43.4 mmHg ± 12.9 in EGJ obstruction, vs 45.3 mmHg ± 17.1 in dilation/deformity, one-way ANOVA P = 0.04) (Figure 1). Conclusion: EGJ opening measures on FLIP are effective at differentiating achalasia treatment failures due to EGJ obstruction vs anatomic changes. An EGJ-DI of < 1 likely indicates recurrent LES dysfunction and may be useful in selecting patients to undergo additional myotomy.Figure 1.: A: Integrated Relaxation Pressure (IRP) in Treatment Failure Subgroups. Blue = EGJ Obstruction. Orange = Recurrent LES Dysfunction. Gray = Dilation/Deformity. EGJ Obstruction vs Recurrent LES, P = 0.78. Recurrent LES vs Dilation/Deformity, P = 0.16. Dilation/Deformity vs EGJ Obstruction, P = 0.29 One-way ANOVA, P = 0.38. 1B: Distensibility Index (DI) in Treatment Failure Subgroups. Blue = EGJ Obstruction. Orange = Recurrent LES Dysfunction. Gray = Dilation/Deformity. EGJ Obstruction vs Recurrent LES, P = 0.002. Recurrent LES vs Dilation/Deformity, P = 0.01. Dilation/Deformity vs EGJ Obstruction, P = 0.78. One-way ANOVA, P = 0.007 1C: Maximum Diameter in Treatment Failure Subgroups. Blue = EGJ Obstruction. Orange = Recurrent LES Dysfunction. Gray = Dilation/Deformity. EGJ Obstruction vs Recurrent LES, P = 0.03. Recurrent LES vs Dilation/Deformity, P = 0.05. Dilation/Deformity vs EGJ Obstruction, P = 0.9. One-way ANOVA, P = 0.055 1D: Maximum Pressure in Treatment Failure Subgroups. Blue = EGJ Obstruction. Orange = Recurrent LES Dysfunction. Gray = Dilation/Deformity. EGJ Obstruction vs Recurrent LES, P = 0.01. Recurrent LES vs Dilation/Deformity, P = 0.04. Dilation/Deformity vs EGJ Obstruction, P = 0.76. One-way ANOVA, P = 0.036. Table 1. - Clinical data showing demographics, first myotomy procedure, recommended intervention after multidisciplinary review of studies, cause of recurrent dysphagia based on review of studies, mean high resolution manometry and functional luminal imaging probe findings Clinical Data Values Age (mean ± SD) 53.7 ± 18.4 Gender (female, n, %) 24, 57.1 BMI (kg/m2) (mean ± SD) 27.3 +/- 7.3 Race (n, %) White 15, 35.7 Black and African American 24, 57.1 Asian 2, 4.8 Unknown 1, 2.4 Ethnicity (n, %) Not Hispanic or Latino 40, 95.2 Hispanic or Latino 2, 4.8 First Myotomy Procedure (n, %) LHM 32, 76.2 POEM 4, 9.5 PD 6, 14.3 Recommended Intervention (n, %) LHM or wrap revision 9, 21.4 POEM 4, 9.5 PD 14, 35.7 Esophagectomy 4, 11.9 Medical therapy 1, 2.4 Watchful waiting 0, 0 Other 7, 19.1 Cause of Recurrent Dysphagia (n, %) Recurrent LES dysfunction 8, 19 EGJ obstruction from fundoplication or LES 12, 29 Esophageal Body Dilatation/Deformity 15, 36 Peptic or Other Stricture 3, 7 Spastic Muscular Segment in Esophageal Body 1, 2 Not enough information/None of the above 3, 7 IRP (mmHg) (mean ± SD) 13.57 ± 6.98 DI @ 60 (mm) (mean ± SD) 3.59 ± 2.08 Max Diameter (mm) (mean ± SD) 14.03 ± 3.85 Max Pressure (mmHg) (mean ± SD) 49.21 ± 16.48 BMI = body mass index. LHM = laparoscopic heller myotomy. POEM = per oral endoscopic myotomy. PD = pneumatic dilation. LES = lower esophageal sphincter. EGJ = esophagogastric junction. IRP = integrated relaxation pressure. DI = distensibility index.

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