Elevated Average Maximum Intrabolus Pressure on High-Resolution Manometry is Associated with Esophageal Dysmotility and Delayed Esophageal Emptying on Timed Barium Esophagram

Background Intrabolus pressure (IBP) recorded by high-resolution manometry (HRM) portrays the compartmentalized force on a bolus during esophageal peristalsis. HRM may be a reliable screening tool for esophageal dysmotility in patients with elevated average maximum IBP (AM-IBP). Timed barium esophagram (TBE) is a validated measure of esophageal emptying disorders, such as esophagogastric junction outflow obstruction and achalasia. This study aimed to determine if an elevated AM-IBP correlates with esophageal dysmotility on HRM and/or delayed esophageal emptying on TBE. Methods A retrospective analysis of all HRM (unweighted sample n=155) performed at a tertiary referral center from 09/2015-03/2017 yielded a case group (n=114) with abnormal AM-IBP and a control group (n=41) with a normal AM-IBP (pressure<17mmHg) as consistent with Chicago Classification 3. All patients received a standardized TBE, with abnormalities classified as greater than 1 cm of retained residual liquid barium in the esophagus at 1 and 5 minutes or as tablet retention after 5 minutes. Results AM-IBP was significantly related to liquid barium retention (p=0.003) and tablet arrest on timed barium esophagram (p=0.011). A logistic regression model correctly predicted tablet arrest in 63% of cases. Tablet arrest on AM-IBP correlated with an optimal prediction point at 20.1 mmHg on HRM. Patients with elevated AM-IBP were more likely to have underlying esophageal dysmotility (95.6% vs. 70.7% respectively; p<0.001), particularly esophagogastric junction outflow obstruction disorders. Elevated AM-IBP was associated with incomplete liquid bolus transit on impedance analysis (p=0.002). Conclusions Our findings demonstrate that an elevated AM-IBP is associated with abnormal TBE findings of esophageal tablet retention and/or bolus stasis. An abnormal AM-IBP (greater than 20.1 mm Hg) was associated with a higher probability of retaining liquid bolus or barium tablet arrest on TBE and esophageal dysmotility on HRM. This finding supports the recent incorporation of IBP in Chicago Classification v4.0.

UCLA Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 Reflux Scale correlates with impaired Esophageal Scintigraphy findings in Systemic Sclerosis

Objective The University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA GIT 2.0) questionnaire is a self-reported tool measuring gastrointestinal (GI) quality of life in systemic sclerosis (SSc) patients. Scarce data are available on the correlation between patient reported GI symptoms and motility dysfunction as assessed by esophageal transit scintigraphy. Methods We evaluated the UCLA GIT 2.0 reflux scale in SSc patients admitted to our clinic and undergoing esophageal transit scintigraphy, and correlated their findings. Results Thirty-one SSc patients undergoing esophageal transit scintigraphy were included. Twentyseven were female, 8 with diffuse cutaneous subset; 26/31 (84%) patients had a delayed transit and an abnormal esophageal emptying activity. Mean (SD) emptying activity percentage was higher in patients with none-to-mild GIT 2.0 reflux score [81.1 (11.5)] than in those with the moderate [55.7 (17.8), p = 0.003] and severe-to-very-severe scores [55.8 (19.7), p = 0.002]. The 26 (84%) SSc patients with delayed esophageal transit had a higher GIT 2.0 reflux score (p=0.04). Percentage of esophageal emptying activity negatively correlated with the GIT 2.0 reflux score (r = - 0.68, p < 0.0001) while it did not correlate with the other scales and the total GIT 2.0 score. Conclusion SSc patients with impaired esophageal scintigraphy findings have a higher GIT 2.0 reflux score. The UCLA SCTC GIT 2.0 is a complementary tool for objective measurement of esophageal involvement which can be easily administered in day-to-day clinical assessment.

Detecting Oropharyngeal and Esophageal Emptying by Submental Ultrasonography and High-Resolution Impedance Manometry: Intubated vs. Non-Intubated Video-Assisted Thoracoscopic Surgery

Postoperative swallowing, affected by general anesthesia and intubation, plays an important part in airway and oral intake safety regarding effective oropharyngeal and esophageal emptying. However, objective evidence is limited. This study aimed to determine the time required from emergence to effective oropharyngeal and esophageal emptying in patients undergoing non-intubated (N) or tracheal-intubated (I) video-assisted thoracoscopic surgery (VATS). Hyoid bone displacement (HBD) by submental ultrasonography and high-resolution impedance manometry (HRIM) measurements were used to assess oropharyngeal and esophageal emptying. HRIM was performed every 10 min after emergence, up to 10 times. The primary outcome was to determine whether intubation affects the time required from effective oropharyngeal to esophageal emptying. The secondary outcome was to verify if HBD is comparable to preoperative data indicating effective oropharyngeal emptying. Thirty-two patients suitable for non-intubated VATS were recruited. Our results showed that comparable HBDs were achieved in all patients after emergence. Effective esophageal emptying was achieved at the first HRIM measurement in 11 N group patients and 2 I group patients (p = 0.002) and was achieved in all N (100%) and 13 I group patients (81%) within 100 min (p = 0.23). HBD and HRIM are warranted for detecting postoperative oropharyngeal and esophageal emptying.

RA06.02: DETECTION OF ALTERED BOLUS TRANSPORT THROUGH THE ESOPHAGUS AND ESOPHAGO-GASTRIC JUNCTION IN PATIENTS WITH HIATUS HERNIA AND DYSPHAGIA

Background Dysphagia can occur in patients with a small hiatus hernia (HH). Whether this relates to a pressure-flow variation through the esophagus or esophago-gastric junction (EGJ) is unknown. Methods High-resolution impedance manometry (HRIM) performed off therapy in 210 reflux patients and 25 age-matched healthy volunteers, recorded 10 × 5mL saline and likewise viscous bolus swallows. Esophageal pressure flow analysis (PFA) with AIMplot v8.0 was undertaken for valid bolus swallows. HRIM EGJ-subtype and endoscopic + /- fluoroscopic imaging enabled HH diagnosis (2–5 cm, > 5 cm excluded). Dysphagia was scored for difficulty swallowing 9 food types (Dakkak and Bennett; 0 none to 45 severe). ANOVA assessed differences in biomechanics of controls and HH + /- patients and dysphagia (D + , > 10/45). Results To date, findings for 135 patients (74M 61F, BMI 28, 19–41) with 70 HH + positive were compared with the 65 HH- negative and 25 healthy controls (7M 18F, BMI 27, 19–37)—see Table. In HH + there was increased resistance (intrabolus pressure) to bolus flow through the esophagus, while pressure during bolus clearance was lower. Further, a higher impedance ratio suggests less effective esophageal emptying, in addition to reduced EGJ outflow time. HH impairs transport of viscous and liquid swallows, affecting patients with HH + and troublesome dysphagia the most. Conclusion A small hiatus hernia alters biomechanics of bolus transport and hinders esophageal and esophago-gastric junction outflow, more so in patients with both dysphagia and hiatus hernia. These findings may relate to altered longitudinal muscle function associated with a short, flaccid esophagus when a hiatus hernia is present. Disclosure All authors have declared no conflicts of interest.

PS01.015: TIMED BARIUM ESOPHAGRAM (TBE) IS RELIABLE IN DEFINING RESPONSE TO TREATMENT AFTER HELLER-DOR FOR ACHALASIA: INITIAL SINGLE CENTER EXPERIENCE

Background Routine timed barium esophagram (TBE), before and after Heller myotomy and Dor funduplication for achalasia, could offer the unique opportunity to objectively measure the outcome of the surgical procedure. In an initial single center experience we aimed at comparing pre-operative and post-operative TBE to objectively measure esophageal emptying and dilation, and to look for possible factors related to surgery results. Methods From 2016 to 2017, 11 patients underwent Heller myotomy and Dor funduplication for achalasia at a single center; all had a pre-operative and post-operative TBE after one month of surgery. TBE measured height and width of barium column at 1 and 5 minutes. All patients were staged according to radiological achalasia staging system: 1 patient was stage 1 (pre-operative esophageal width between 2 and 3 cm), 4 stage 2 (4–6 cm) and 6 stage 3 (> 6 cm). TBE height and width at 1 and 5 minutes were compared between pre-operative and post-operative TBE by the Wilcoxon signed-rank test. Moreover the association between surgery results and possible risk factors was evaluated by Spearman's rho. Results TBE height and width at 1 minute decreased in median by 79% (range 17–100%) and 57% (37–100%), respectively, from pre-operative to post-operative TBE. The decrease was more pronounced at 5 minutes, where it was 85% (40–100%) and 71% (40–100%), respectively. Although all patients reported a significant subjective improvement in symptoms, radiological stage was associated to esophageal emptying: the 4 subjects in stage 2 and the subject in stage 1 had complete or near complete emptying at 5 minutes, while the 6 patients in stage 3 had a median percent decrease at 5 min in height of 75% (40–86%) and in width of 50% (40–71%) (Spearman's rho for height = -0.87, P < 0.001; Spearman's rho for width = -0.88, P < 0.001). Conclusion TBE is essential post myotomy, particularly if a substantial esophageal dilatation occurs pre-operatively (stage 3). Initial stage is associated with surgical outcomes, advanced stages being related to poorer emptying and more dilated esophagus after surgery. TBE is a reliable system to objectively define surgical outcomes and preserved esophageal function after Heller-Dor procedure. Disclosure All authors have declared no conflicts of interest.