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Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia—Anatomy Matters!

Jain, Anand S. MD1; Carlson, Dustin A. MD, MS2; Triggs, Joseph MD2; Tye, Michael BA2; Kou, Wenjun PhD2; Campagna, Ryan MD3; Hungness, Eric MD3; Kim, Donald MD4; Kahrilas, Peter J. MD2; Pandolfino, John E. MD, MS2

American Journal of Gastroenterology: September 2019 - Volume 114 - Issue 9 - p 1455–1463
doi: 10.14309/ajg.0000000000000137

INTRODUCTION: To compare the utility of the distensibility index (DI) on functional lumen imaging probe (FLIP) topography to other esophagogastric junction (EGJ) metrics in assessing treatment response in achalasia in the context of esophageal anatomy.

METHODS: We prospectively evaluated 79 patients (at ages 17–81 years; 47% female patients) with achalasia during follow-up after pneumatic dilation, Heller myotomy, or per-oral endoscopic myotomy with timed barium esophagram, high-resolution impedance manometry, and FLIP. Anatomic deformities were identified based on consensus expert opinion. Patients were classified based on anatomy and EGJ opening to determine the association with radiographic outcome and Eckardt score (ES).

RESULTS: Twenty-seven patients (34.1%) had an anatomic deformity—10 pseudodiverticula at myotomy, 7 epiphrenic diverticula, 5 sigmoid, and 5 sinktrap. A 5-minute column area of >5 cm2 was best associated with an ES of >3, with a sensitivity of 84% (P = 0.0013). Area under the curve for EGJ metrics in association with retention was as follows: DI, 0.90; maximal EGJ diameter, 0.76; integrated relaxation pressure, 0.64; and basal esophagogastric junction pressure, 0.53. Only FLIP metrics were associated with retention given normal anatomy (DI 2.4 vs 5.2 mm2/mm Hg and maximal EGJ diameter 13.1 vs 16.6 mm in patients with and without retention, respectively; P values < 0.0001 and 0.002). Using a DI cutoff of <2.8 as abnormal, 40 of 45 patients with retention (P = 0.0001) and 23 of 25 patients with an ES of >3 (P = 0.02) had a low DI and/or anatomic deformity. With normal anatomy, 21 of 22 patients with retention had a low or borderline low DI.

DISCUSSION: The FLIP DI is most useful metric for assessing the effect of achalasia treatment on EGJ opening. However, abnormal anatomy is an important mediator of outcome and treatment success will be modulated by anatomic defects that impede bolus emptying.

1Division of Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, Georgia, USA;

2Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois, USA;

3Division of Gastrointestinal Surgery, Northwestern Medicine, Chicago, Illinois, USA;

4Division of Radiology, Northwestern Medicine, Chicago, Illinois, USA.

Correspondence: Anand S. Jain, MD. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at

Received August 16, 2018

Accepted December 17, 2018

Online date: February 05, 2019

© The American College of Gastroenterology 2019. All Rights Reserved.
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