Is EndoFLIP Useful for Predicting Clinical Outcomes after Peroral Endoscopic Myotomy in Patients with Achalasia?

Gwang Ha Kim

摘要

The esophagogastric junction (EGJ) is a complex anatomic and functional zone that has paradoxical actions, such as allowing food passage into the stomach after swallowing and maintaining a tightly closed anti-reflux barrier. The delicate EGJ balance requires the harmonious interactions of the lower esophageal sphincter (LES), crural diaphragm, luminal geometry, and the inherent mechanical characteristics of the EGJ. 1 High-resolution manometry (HRM) and timed barium esophagography (TBE) are the two main modalities used to measure the surrogate parameters of EGJ opening, such as deglutitive EGJ relaxation pressure and bolus retention. Recently, the endoluminal functional lumen imaging probe (EndoFLIP) was developed to evaluate the pathogenesis of EGJ diseases. The EndoFLIP uses impedance planimetry for real-time measurement of the EGJ cross-sectional area (CSA), the corresponding pressure, and EGJ distensibility. EGJ distensibility can be expressed as the distensibility index (DI), defined as the CSA divided by the pressure, and represents the degree of impaired LES relaxation. Achalasia is a primary esophageal motility disorder associated with functional obstruction at the EGJ level due to defective LES relaxation. Current treatment options for achalasia focus on the relief of this functional obstruction. Of these treatments, peroral endoscopic myotomy (POEM), is an emerging minimally invasive treatment modality that provides an alternative to surgical myotomy. Recent studies have shown that POEM is a highly effective treatment for achalasia in terms of both symptomatic relief and improved esophageal physiology. 2 , 3 In practice, predicting post-treatment outcomes is important, including after POEM. However, there is a paucity of objective modalities for determining the extent of the myotomy and the post-POEM relaxation impairment. In the case of pneumatic dilation, a low post-dilation LES pressure (&10 mm) is reported to be predictive of favorable long-term outcomes. 4 In addition, physiologic evaluation of the EGJ opening, such as HRM-determined LES relaxation pressure and TBE-determined bolus retention, can determine post-treatment outcomes in patients with achalasia; 5 , 6 however, these tests are suboptimal. Evaluation of EGJ distensibility, such as EndoFLIP DI, may be another option for determining post-POEM outcomes. In a previous study, the DI was well correlated with both the Eckardt score and the HRM-determined integrated relaxation pressure. Further, the DI was significantly less than normal in patients with poor treatment responses whereas patients with good treatment responses demonstrated significantly greater EGJ distensibility than did those with poor responses. 1 In this issue of Gut and Liver , Yoo et al . 7 reported that post-treatment DI by EndoFLIP is useful for predicting POEM clinical outcomes in patients with achalasia. Changes in LES pressures and integrated relaxation pressures, after POEM, and a low post-treatment DI (&7 mm ~(2)/mm Hg) during volume-controlled distension (using 30 mL or 40 mL of saline) was associated with a high rate of incomplete responses, after POEM. In a multivariate analysis, a post-treatment DI &7 mm ~(2)/mm Hg was the most important predictor of an incomplete response. Then, what are the optimal clinical DI values following POEM? Predicting the clinical response to POEM and the future occurrence of post-treatment gastroesophageal reflux seems helpful. In fact, the most common adverse event after POEM is gastroesophageal reflux; the prevalence of abnormal esophageal acid exposure on pH monitoring after POEM has been reported to be 20%–57%. 8 In a study involving EndoFLIP in patients undergoing Heller myotomy and POEM, a final post-treatment DI of 4.5–8.5 mm ~(2)/ mm Hg was suggested to be the ideal final DI range for achieving optimal symptomatic outcomes, that is, Eckardt scores ≤1 and GerdQ scores ≤7. 9 On the other hand, Yoo et al . 7 recommend a post-treatment DI of 7–10 mm ~(2)/mm Hg for predicting minimal dysphagia and minimal gastroesophageal reflux disease, after POEM. These differences may be caused by the variability in the patient numbers, clinical response definitions, and EndoFLIP timing. Moreover, comparing EndoFLIP data between centers is difficult due to the variety of results described in previous studies. 9 When is the proper time to perform EndoFLIP to predict post-POEM clinical outcomes? Recent studies have shown increased EGJ distensibility either immediately post-procedure or 3 months after treatment with pneumatic dilation, laparoscopic Heller myotomy, or POEM was predictive of postoperative symptomatic outcomes. 3 , 9 However, there are several limitations regarding the intraoperative measurement of EGJ distensibility after POEM. Because POEM procedures are performed under general anesthesia, the drugs used can influence muscle tone even though the effects of general anesthesia on EGJ distensibility are negligi

机译：食管胃交界处（EGJ）是一个复杂的解剖学和功能区，具有悖论性的作用，例如吞咽后允许食物进入胃中并保持紧密封闭的抗反流屏障。精细的EGJ平衡需要食管下括约肌（LES），关键diaphragm肌，管腔几何形状和EGJ固有的机械特性之间的和谐相互作用。 1高分辨率测压法（HRM）和定时钡剂食管造影术（TBE）是用于测量EGJ开口替代指标的两种主要方式，例如EGJ松弛胶凝作用和推注滞留。最近，开发了腔内功能管腔成像探针（EndoFLIP）来评估EGJ疾病的发病机理。 EndoFLIP使用阻抗平面仪实时测量EGJ截面积（CSA），相应的压力和EGJ膨胀性。 EGJ的可扩张性可以表示为可扩张性指数（DI），定义为CSA除以压力，代表LES松弛受损的程度。失语症是一种原发性食管动力障碍，与LES松弛不良相关，在EGJ级功能性阻塞。门失弛缓症的当前治疗选择集中于缓解这种功能性阻塞。在这些治疗方法中，经口内镜下肌切开术（POEM）是一种新兴的微创治疗方法，为手术肌切开术提供了另一种选择。最近的研究表明，就症状缓解和改善的食道生理而言，POEM是治疗门失弛缓症的高效方法。 2，3实际上，预测治疗后的结果非常重要，包括在POEM之后。但是，缺乏确定肌切开术和POEM后松弛损伤程度的客观方法。在进行气动扩张的情况下，据报道低的扩张后LES压力（＜10mm）可预示良好的长期结果。 4此外，EGJ开口的生理评估，例如HRM决定的LES放松压力和TBE决定的推注retention留，可以确定门失弛缓患者的治疗后结局。然而，在图5、6中，这些测试不是最佳的。 EGJ可扩展性的评估（例如EndoFLIP DI）可能是确定POEM后结果的另一种选择。在先前的研究中，DI与Eckardt评分和HRM确定的综合舒张压高度相关。此外，在治疗反应较差的患者中，DI明显低于正常水平，而在治疗反应良好的患者中，其表现出的EGJ可扩张性明显高于反应较差的患者。 1在本期《肠道与肝脏》中，Yoo等人。 7报道EndoFLIP治疗后的DI可用于预测is门失弛缓患者的POEM临床结果。 POEM后LES压力和综合松弛压力的变化以及在体积控制性扩张期间（使用30 mL或40 mL盐水）的低后处理DI（<7 mm〜（2）/ mm Hg）与在POEM之后，不完整的回复率很高。在多变量分析中，治疗后DI ＜7 mm〜（2）/ mm Hg是反应不完全的最重要预测指标。那么，POEM后的最佳临床DI值是多少？预测对POEM的临床反应以及治疗后胃食管反流的未来发生似乎很有帮助。实际上，POEM术后最常见的不良事件是胃食管反流。据报道，POEM后在pH监测中异常食管酸暴露的发生率为20％–57％。 [8]在一项涉及进行Heller肌切开术和POEM的患者的EndoFLIP的研究中，建议最终治疗后DI为4.5-8.5 mm〜（2）/ mm Hg，是达到最佳症状结果的理想最终DI范围，即， Eckardt分数≤1，GerdQ分数≤7。 9另一方面，Yoo等。 7建议在POEM之后，治疗后DI为7-10 mm〜（2）/ mm Hg，以预测最小的吞咽困难和最小的胃食管反流病。这些差异可能是由患者人数，临床反应定义和EndoFLIP时机的差异引起的。此外，由于先前研究中描述的结果多种多样，因此很难比较各中心之间的EndoFLIP数据。 9什么时候才是进行EndoFLIP预测POEM后临床结果的适当时间？最近的研究表明，在手术后即刻或气动扩张，腹腔镜Heller肌切开术或POEM治疗后3个月，EGJ扩张性增加可预示术后症状预后。 [3，9]但是，POEM后术中测量EGJ扩张性存在一些限制。因为POEM程序是在全身麻醉下进行的，所以即使全身麻醉对EGJ扩张性的影响是疏忽大意，所使用的药物也会影响肌张力

Is EndoFLIP Useful for Predicting Clinical Outcomes after Peroral Endoscopic Myotomy in Patients with Achalasia?

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