Yervant Ichkhanian, MD1, Andrew Canakis, DO2, Sabine Roman, MD, PhD3, In Kyung Yoo, MD4, Rishi Pawa, MD, FACG5, Robert Dorrell, MD6, Kenneth Koch, MD7, Bailey Su, MD8, Michael Ujiki, MD9, Mouen Khashab, MD10; 1Johns Hopkins University Hospital, Baltimore, MD; 2Boston University Medical Center, Boston, MA; 3Edouard Herriot Hospital, Lyon, Auvergne, France; 4CHA Bundang Medical Center, Baltimore, MD; 5Wake Forest University, Winston-Salem, NC; 6Wake Forest University, School of Medicine, Winston-Salem, NC; 7Wake Forest Baptist Health, Winston-Salem, NC; 8NorthShore University Health System, Evanston, IL; 9Northshore University HealthSystem, Evanston, IL; 10Johns Hopkins University School of Medicine, Baltimore, MD
Introduction: Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller myotomy (LHM) have evolved as effective management tools in relieving lower esophageal sphincter (LES) pressure in patients with esophageal motility disorders. However, a small percentage of patients fail to improve or relapse after time. The challenge remains in identifying the patients who might benefit from repeat myotomy as opposed to conservative managements. In the following study, we describe the role of endolumenal functional lumen imaging probe (EndoFLIP), in addition to high-resolution manometry (HRM), for managing such patients. Methods: This was a multicenter, international retrospective study conducted between January 2015 and October 2019. Patients with a diagnosis of achalasia, esophagogastric junction outflow obstruction (EGJOO), diffuse esophageal spasm (DES), or jackhammer esophagus (JE) who underwent a prior failed myotomy were included. Clinical success of post repeat myotomy in the form of POEM was considered the primary outcome. Results: A total of 72 patients [Female= 28 (39%), mean age 55±17.3] with clinical failure and Eckardt score (ES) > 3 who underwent post LHM (33) or POEM (39) were included. On HRM evaluation, 27 were deemed candidates for repeat myotomy based on abnormal integrated relaxation pressure (IRP) measurements >15mmHg. On EndoFLIP evaluation,13/27 had an abnormal distensibility index (DI) < 2.8 mm2/mmHg at 40 ml balloon volume distension (Figure 1). A total of 30 patients underwent conservative management - pneumatic balloon dilation (n=9) and repeat myotomy (n=33) (Table 1). Post repeat myotomy mean ES improved from 5.8±2.7 to 1.1±1.4, (p< 0.001), and median DS improved from 2 (IQR: 1-3) to 1 (0-2), (p=0.03), at a median follow-up time of 2 (IQR: 0-4.5) months post-procedure. Clinical success was achieved in 23/33 (70%) of the patients (Table 2). DI at 40 m balloon distension volume (p=0.01; odds ratio, 1.51; 95% confidence interval, 1.02-2.1) was identified to be the best independent predictors of clinical success post repeat myotomy, with DI < 3.3 mm2/mmHg having sensitivity and specificity of 64% and 80%, respectively, for predicting clinical success. Therefore, the theoretical impact of EndoFLIP utilization for the management and diagnosis was in 16/72 (22%). Discussion: The findings of this study demonstrate the important role of using EndoFLIP, in addition to HRM, in evaluating patients with clinical failure post myotomy.
Disclosures: Yervant Ichkhanian indicated no relevant financial relationships. Andrew Canakis indicated no relevant financial relationships. Sabine Roman indicated no relevant financial relationships. In Kyung Yoo indicated no relevant financial relationships. Rishi Pawa indicated no relevant financial relationships. Robert Dorrell indicated no relevant financial relationships. Kenneth Koch indicated no relevant financial relationships. Bailey Su indicated no relevant financial relationships. Michael Ujiki indicated no relevant financial relationships. Mouen Khashab: Boston Scientific – Consultant. Medtronic – Consultant. Olympus – Consultant.