Contractility patterns on functional lumen imaging probe prior to peroral endoscopic myotomy predict outcomes in achalasia.

BACKGROUND AND AIMS: Functional lumen imaging probe (FLIP) assessment of esophagogastric junction (EGJ) opening confirms suspected achalasia. However, the importance of the contractile response (CR) in the esophageal body to volumetric distension in established achalasia is unclear. This study evaluated the value of CR on FLIP before peroral endoscopic myotomy (POEM) to predict post-POEM esophageal emptying on timed barium esophagram (TBE).

METHODS

Patients with types 1 and 2 achalasia who underwent FLIP at a tertiary center from March 2020 to June 2024 were identified. FLIP was interpreted using published criteria, with reduced EGJ opening (REO) defined by distensibility index (DI) <2 mm2/mm Hg and maximum diameter <12 mm at 60 and 70 mL balloon volume, respectively, and CR categorized as normal, spastic, disordered/diminished, or absent. Outcome measures included significant barium retention on TBE, defined by column height greater than 5 cm at 5 minutes or 13-mm barium tablet retention.

RESULTS

Among 141 patients (48.2% female; median age, 60.0; IQR, 44.0-73.0 years; 123 (74.1%) type II achalasia), all had reduced EGJ opening on FLIP pre-POEM, with absent CR in 111 (78.7%). Significant barium retention on TBE was observed in 29.1% post-POEM, with absent CR on pre-POEM FLIP associated with barium retention on TBE (RR, 3.0; 95% CI, 1.1-9.1; P = .033) and greater mean column height at 5 minutes (1.8 cm vs 0.4 cm; P = .042).

CONCLUSIONS

Absent CR on FLIP prior to POEM predicts significant barium retention on TBE after POEM, supporting an additive diagnostic role for FLIP in achalasia therapeutic outcome predictions.