Aws Hasan, MD1, Eric Low, MD, MPH2, Alex Kaizer, PhD3, Syed Abbas Fehmi, MD1, Wilson Kwong, MD2, Mary L. Krinsky, DO4, Michael Chang, MD2, Gobind Anand, MD2, Madeline Greytak, BS5, Rena Yadlapati, MD, MS2 1UCSD, San Diego, CA; 2University of California San Diego, San Diego, CA; 3University of Colorado School of Medicine, Denver, CO; 4University of California San Diego School of Medicine, La Jolla, CA; 5University of California San Diego, La Jolla, CA
Introduction: Myotomy with proximal extension is the first-line treatment for type 3 achalasia, and myotomy length is typically based on length of spastic segment on high resolution manometry (HRM). The diagnostic potential of length of tertiary contractions on barium esophagram (BE) or length of thickened circularis muscle on endoscopic ultrasound (EUS) to guide myotomy length are less understood. This study aimed to assess agreement between length of spastic segments on HRM, BE, and EUS among patients with type 3 achalasia.
Methods: This retrospective single center study evaluated adult patients with type 3 achalasia diagnosed by HRM who underwent evaluation with EUS between 11/2019 to 03/2021. EUS was performed during a sedated upper endoscopy and measurements of the circular muscle thickness were taken at the LES and every cm proximal until the muscle thickness reached 1mm or less. Spastic segments were defined as follows: HRM (Medtronic, Minneapolis, MN) - axial distance between proximal border of LES to proximal border of premature contraction; EUS - length of thickened circular muscle from proximal border of LES to the transition point of thickened to normal thickness circular muscle; BE - axial distance between esophagogastric junction to proximal border of tertiary contractions (corkscrew pattern). Pearson’s correlation and intraclass correlation coefficient (ICC) were used to assess diagnostic agreement.
Results: 8 patients with type 3 achalasia on HRM underwent EUS [mean age 71.3 yrs (SD 10.0), 5 (63%) male] and 7/8 underwent BE. Mean spastic segment on HRM was 12.4 cm (SD 3.9 cm), EUS 9.6 cm (SD 4.9 cm) and BE 13.2 cm (SD 2.7 cm). Overall measures of agreement between the 3 diagnostic modalities were weak. There was a strong positive relationship between spastic segment on HRM and BE (Pearsons 0.766) with moderate ICC agreement (0.70 (95% CI 0.06, 0.94) (Figure 1, 2). There was poor agreement between spastic segment on EUS and BE (Pearsons 0.10; ICC agreement 0.07 (-0.53, 0.72)) as well as HRM and EUS (Pearsons 0.38; ICC agreement -0.37 (-0.88, 0.43)).
Discussion: Among patients with type 3 achalasia there was a moderate to strong agreement for the length of spastic segment on HRM and BE, however there was poor agreement with EUS compared to HRM or BE. These data, limited by a small sample size, suggest an uncertain role for EUS in tailoring myotomy length for type 3 achalasia.
Figure: Figure 1.Scatterplot of pairwise comparisons of modalities Figure 2.Comparison of Length of Spastic Segment on HRM and BE This is an example that demonstrates correlation between length of spastic segment on HRM and BE. Our patient here has about a 10 cm spastic segment measured on manometry, compared to about 12 cm measured on barium esophagram.
Aws Hasan indicated no relevant financial relationships.
Eric Low indicated no relevant financial relationships.
Alex Kaizer indicated no relevant financial relationships.
Syed Abbas Fehmi: Boston Scientific – Consultant. Cook Endoscopy – Consultant.
Wilson Kwong indicated no relevant financial relationships.
Mary Krinsky indicated no relevant financial relationships.
Michael Chang indicated no relevant financial relationships.
Gobind Anand indicated no relevant financial relationships.
Madeline Greytak indicated no relevant financial relationships.
Rena Yadlapati: Ironwood – Grant/Research Support, Institutional Consulting Agreement. Medtronic – Other Financial or Material Support, Institutional Consulting Agreement. Phathom Pharmaceuticals – Consultant. RJS Mediagnostics – Advisory Committee/Board Member.
Aws Hasan, MD1, Eric Low, MD, MPH2, Alex Kaizer, PhD3, Syed Abbas Fehmi, MD1, Wilson Kwong, MD2, Mary L. Krinsky, DO4, Michael Chang, MD2, Gobind Anand, MD2, Madeline Greytak, BS5, Rena Yadlapati, MD, MS2. P2386 - Utility of High Resolution Manometry, Barium Esophagram and Endoscopic Ultrasound to Assess Length of Spastic Segment in Type 3 Achalasia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.