Advances in Management of Esophageal Motility Disorders

Abstract

The widespread adoption of high-resolution manometry (HRM) has led to a restructuring in the classification of esophageal motility disorder classification summarized in the Chicago Classification, currently in version 3.0. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or even with preserved peristalsis. Furthermore, despite these advances in diagnostics, no single manometric pattern is perfectly sensitive or specific for idiopathic achalasia and complimentary assessments with provocative maneuvers during HRM or interrogating the esophagogastric junction with the functional luminal imaging probe during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. Using these tools, we have come to conceptualize esophageal motility disorders as characterized by obstructive physiology at the esophagogastric junction, smooth muscle esophagus, or both. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. Now and going forward, optimal management is to render treatment in a phenotype-specific manner: e.g. POEM calibrated to patient-specific physiology for spastic achalasia and spastic disorders of the smooth muscle esophagus, more conservative strategies (pneumatic dilation) for the disorders limited to the sphincter.

Jackhammer esophagus with and without esophagogastric junction outflow obstruction demonstrates altered neural control resembling type 3 achalasia

“…Our findings lend support to not just exaggerated excitation but also abnormal inhibition in the pathophysiology of hypercontractile disorders and demonstrate that both jackhammer esophagus and jackhammer with obstruction share similar pathophysiology with type 3 achalasia. This common pathophysiologic thread indirectly supports the concept of obstructive esophageal body and EGJ physiology in many of the major motor disorders, necessitating a similar management approach. Tailored per oral endoscopic myotomy (POEM) is an attractive potential option especially when alternate structural etiologies are not implicated.…”

Upper esophageal sphincter metrics on high‐resolution manometry differentiate etiologies of esophagogastric junction outflow obstruction

“…One of the prevailing concerns of the esophagologist is the overdiagnosis of conditions that may not improve regardless of medical, endoscopic, or surgical management. Because EGJOO encompasses many etiologies and even at times may be considered a false positive finding, society recommendations have been conservative regarding treatment . Our study represents a large analysis of patients with EGJOO as well as the largest such cohort to receive treatment via myotomy.…”

Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

“…Balloon dilation is currently the most commonly used treatment modality because it is relatively easy to perform and noninvasive and does not require special training . However, because the shearing effect of BD is localized to the EGJ, BD is recommended for treatment of achalasia types I and II, albeit merely by expert opinions only and without definite evidence …”

“…For type III achalasia, POEM is recommended . Introduced in 2010, POEM uses an endoscopic knife to make mucosal incision inside the esophagus and submucosal tunnel up to the gastric cardia .…”

“…Introduced in 2010, POEM uses an endoscopic knife to make mucosal incision inside the esophagus and submucosal tunnel up to the gastric cardia . In POEM, the exact length of esophageal hypercontractility and EGJ outflow obstruction can be dissected in a tailored manner, thus making it ideal for type III achalasia, which involves both the EGJ and the esophageal body . Although POEM now represents one of the most advanced treatment methods for achalasia, only a limited number of studies based on small number of patients have compared the treatment outcomes of patients treated with either BD or POEM .…”