Tu1172 Correlation Between High-Resolution Manometry Metrics and Symptoms, Symptomatic Outcomes of Peroral Esophageal Myotomy in Achalasia

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integrated relaxation pressure were calculated for the ten single swallows, and Chicago Classification (CC) algorithm was applied. Response to MRS was evaluated for presence or absence of peristaltic contraction, and for augmentation, defined as a DCI after MRS greater than average DCI for the ten single swallows. Dysphagia was assessed by questionnaire at the time of HRM, and the measured dysphagia score was based on severity and frequency. Results: 18 healthy controls (56% F, mean age 27) and 71 SCL patients (79% F, mean age 53, 73% with dysphagia) were included. Absent peristalsis (39%) was the most frequent CC diagnosis in SCL patients; other diagnoses included ineffective esophageal motility (IEM, 17%), EGJ outflow obstruction (9%), Jackhammer esophagus (3%), distal esophageal spasm and achalasia type III (1% each); 30% of studies were normal. Following MRS, contraction was present in 100% controls and 34% SCL (p<0.0001), while augmentation was seen in 83% controls and 20% SCL (p<0.0001). In SCL, failure to contract was seen in 96% with absent peristalsis, and 83% with IEM, but only in 32% in the remainder (p<0.0001). There was no statistically significant association between dysphagia score and aperistalsis, IEM, or parameters of response to MRS. Conclusions: Dysphagia severity did not correlate with CC diagnosis of aperistalsis/IEM, or with MRS response. Failure to contract or augment after MRS were the most frequent abnormalities in SCL patients, more common than absent peristalsis or IEM. Furthermore, failure to contract after MRS was never seen in controls but was frequent in SCL. These findings indicate that loss of peristaltic reserve determined by MRS is the most frequent manometric abnormality in SCL patients.

Tu1171 Influence of Peroral Esophageal Myotomy (POEM) on Esophageal Motility of Achalasia Patients Yue Hu, Lu Bin, Meng Li Background:High-resolution manometry (HRM) is an accurate method to evaluate the esophageal motility of achalasia patients. Aim: To assess the influence of peroral esophageal myotomy (POEM) on esophageal motility in patients with achalasia by analyzing the dynamic changes in HRM. Methods:From January 2012 to November 2014, forty-one patients with achalasia underwent POEM. Esophageal motility of all patients was evaluated both preoperatively and one month after POEM treatment using a high-resolution manometry (HRM) system, which was performed with 10 water swallows, 10 steamed bread swallows and multiple rapid swallows (MRS). Data of manometry, including lower esophagus sphincter resting pressure (LESP), 4-second integrated relaxation pressure (4sIRP), lower esophageal sphincter relaxation rate (LESRR), distal contractile integral (DCI), intra bolus pressure (IBP) and distal esophageal peristaltic amplitude, was analyzed to evaluate the outcomes. Results:In single swallows, including liquid swallows and bread swallows, the parameters of LESP, 4sIRP and IBP between pre- and post-POEM patients all decreased(P<0.05), with the significant difference being increasing change in LESRR(P<0.05). It had positive correlation between decline of IRP and reduced degree of symptom scores (P<0.05). At postoperatively, the trend of DCI and distal esophageal peristaltic amplitude was declined in subtype II and subtype III(subtype II: P<0.05; subtype III: P>0.05), which was increased in subtype I(subtypeI: P>0.05). In liquid swallows, the Eckardt score of subtype II patients with descension of DCI and distal esophageal peristaltic amplitude after POEM, were significantly lower than those with ascension of this two parameters(P<0.05). In MRS, the rate of LES relaxation increased from 66.67% to 95.24%, but without normal response to MRS in all achalasia patients. Clinical symptomatic improvement was achieved in all patients at one-month follow-up (P=0.000). Conclusion:POEM can reduce LES pressure of achalasia, and restore a certain degree of esophageal body motility function, furthermore, it has different effect on esophageal motility in different pattern of swallowing. Interesting, the change in parameters of esophageal body peristalsis may correlated with the decrease in Eckardt score.

Tu1170 Younger Male Achalasia Patients Do Not Require Larger Initial Balloon Size for Effective Pneumatic Dilation Aaron P. Balinski, Carolyn T. Hogan, Deena Midani, Henry P. Parkman, Frank K. Friedenberg, Robert S. Fisher, Joel Richter, Michael S. Smith Background: Pneumatic balloon dilation (PD) under fluoroscopic guidance is an established treatment for achalasia. Balloons come in 3 diameters: 30, 35 and 40 mm. Most initial PD are performed with 30 mm balloons, but some guidelines suggest men under age 45 should start at 35 mm. Our aim was to compare initial PD treatment efficacy with respect to age and balloon size in male achalasia patients. Methods: All PD at our institution from July 2007 through October 2014 were reviewed. Male patients were included in the analysis if their chart had no evidence of earlier PD or surgical myotomy. Prior botulinum toxin injection (BTI) or endoscopic balloon dilation up to 20 mm was permitted. Patients who had a complication of PD were excluded from duration of efficacy analysis. Repeat treatment was defined as any subsequent PD, BTI or surgical myotomy. Analysis was performed using Chi-square tests. Results: During the study period, 233 PD were performed on 191 patients (87 men). Of the 104 PD in males, 2 men (1.9%), ages 68 and 88 years, had perforations after 30 mm PD. Both patients underwent surgical repair. A total of 75 cases met inclusion criteria. Overall, 64 (85%) of study cases had 30 mm PD as initial treatment and 11 had 35 mm PD. Repeat intervention was documented in 16 patients (25%) who first had 30 mm PD and 1 patient (9%) with 35 mm PD (p=0.244). There were 21 men under age 45 (28%). Of this group, 14 had initial treatment with 30 mm PD and 7 had 35 mm PD. Repeat intervention was needed in 4 patients (29%) in the 30 mm group, on average 545 days after PD (219-876). The 10 patients who did not have additional treatment after 30 mm PD were followed an average of 1101 days (239-2452). One patient (14%) required intervention after initial 35 mm PD, 485 days later. The six patients who did not receive additional treatment after 35 mm PD were followed an average of 1111 days (178-2076). The difference in need to retreat based on balloon size again did not reach statistical significance (p=0.469). Of the 54 men over age 45, 50 (93%) had 30 mm PD as initial treatment and 12 (24%) required repeat intervention. None of the 4 older patients who had initial 35 mm PD needed additional treatment. The difference in need for retreatment did not reach statistical significance in this cohort (p=0.267). Conclusions: Overall, 77% of male patients who had PD did not require further treatment, in line with other studies. While younger males who had initial 30 mm PD required more subsequent interventions than those who had 35 mm PD, the difference was not statistically significant. Also, 71% of younger 30 mm PD patients did not require an additional procedure. This success rate was similar to older patients, in whom 76% did not require repeat treatment after 30 mm PD. Given these results, starting with 30 mm PD in young males remains a reasonable option. Pneumatic Dilation Results for Male Patients

Figure 1: The relationship between alterability of DEPA and Eckardt score in subtype II patients.In liquid swallows, the Eckardt score of subtype II patients with descension of DEPA after POEM, was significantly lower than those with ascension of this two parameters(P<0.05), but with no statistical significant difference in bread swallows(P>0.05).{BR}DEPA, distal esophageal peristaltic amplitude.

Figure 2: The relationship between alterability of DCI and Eckardt score in subtype II patients.In liquid swallows, the Eckardt score of subtype II patients with descension of DCI after POEM, was significantly lower than those with ascension of this two parameters(P<0.05), but with no statistical significant difference in bread swallows(P>0.05).DCI, distal contractile integral. Tu1172 Correlation Between High-Resolution Manometry Metrics and Symptoms, Symptomatic Outcomes of Peroral Esophageal Myotomy in Achalasia Yu R. Tang, Lin Lin BACKGROUND & AIM: High-resolution manometry (HRM) has improved the accuracy of manometry in detecting achalasia and defined clinically relevant subtypes. Few researches have reported the relationship of HRM metrics and severity of symptoms in achalasia. Peroral esophageal myotomy (POEM) is a novel endoscopic operation performed for the treatment of achalasia. This study investigated whether HRM metrics correlate with achalasia symptoms and symptomatic outcomes of POEM. METHODS: Thirty patients with achalasia without previous surgery, and who underwent HRM were enrolled. Twenty-five patients were treated with POEM, and 12 patients repeat HRM detection 3 months after POEM. All of the patients enrolled at the beginning were asked to complete questionnaires that determined Eckardt scores at baseline, and symptoms of patients who treated with POEM were followed up about 6 months after surgery. RESULTS: Thirteen type I, 16 type II and 1 type III achalasia patients were enrolled. At baseline, Eckardt scores and HRM metrics [integrated relaxation pressure (IRP), resting lower esophageal sphincter pressure (LESP), LES length (LESL)] were similar between type Iand typeII achalasia except mean distal esophageal pressure (DEP) in swallows (P=0.000), and panesophageal pressurization rate (PPR) in type II achalasia was rage from 20% to 100%. IRP was positively correlated with total Eckardt Scores (P=0.016),

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dysphagia scores in patients with intact peristalsis (n=19) to those with weak peristalsis and/ or frequent failed peristalsis (n=17).The mean dysphagia scores were 2.0 and 1.1 at baseline (p=0.24), 2.5 and 2.1 at 1-2 months postop (p=0.32), and 0.7 and 0.7 at 3+ months postop (p=0.65) for patients with intact peristalsis and those with weak and/or frequent failed peristalsis, respectively. Conclusions: Our aim was to evaluate for dysphagia following magnetic sphincter augmentation with the LINX device in those with weak peristalsis and frequent failed peristalsis on preoperative manometry. When compared to controls with intact peristalsis, we find no difference in dysphagia scores (all p values > 0.05) at 12 months postoperatively and at 3+ months postoperatively. Therefore, performing LES augmentation surgery in refractory GERD patients with weak or frequently failed peristalsis on preoperative manometry does not appear to affect postoperative dysphagia. The overall improvement in dysphagia after the third postoperative month suggests that dysphagia was secondary to either the surgery itself, esophageal dysmotility from GERD or visceral hypersensitivity, all of which could improve postoperatively. Tu1174 Correlates of Various Impaired Esophageal Motility Parameters With Incomplete Bolus Transit in the Esophagus Jie Guo, Zhaohong Shi, Xinjun Wan, Haifeng Jin, Nina Zhang, John O. Clarke, Ellen M. Stein, Sameer Dhalla, Pankaj J. Pasricha, Jiande Chen High-resolution esophageal manometer (HREM) is an important method used to assess and diagnose esophageal motility diseases. However, the relationship between motility abnormalities defined in Chicago Classification and bolus transit is not clearly understood. The aim of this study was therefore to determine the roles of various motility parameters in predicting impaired bolus transit in the esophagus. Methods: A total of 703 wet swallows were analyzed in 80 patients (37 male, mean age of 51) who underwent the simultaneous HREM and impedance testing. Following esophageal motility abnormalities were analyzed and identified: abnormal IRP (>15mmHg), failed contraction (DCI<500), weak peristalsis (large/small breaks), simultaneous contractions, hyper-contraction (DCI>5000) and multiple impairment (LES impairment plus one of esophageal body impairment). Each swallow was classified as complete or incomplete bolus clearance according to the impedance measurement. RESULTS: In the proximal esophagus, incomplete bolus clearance (IBC) was observed in 15.4% (108/703) of swallows. Simultaneous contractions were associated with a higher IBC rate than peristaltic contractions (73.1% vs. 12.8%, P < 0.01). Large breaks and small breaks were associated with a higher IBC rate than normal contractions (31.6% vs.11.1%, P < 0.01 and 23.6% vs.11.1%, P < 0.01). There was no significant difference in IBC between large and small breaks. In the distal esophagus, IBC was observed in 23.3% (164/703) of swallows. Simultaneous contractions, failed contractions (DCI<500) and large but not small breaks were associated with a higher IBC rate than normal contractions (88.5%, 64.8%, and 47.4%, P < 0.01 each vs. normal contractions). Surprisingly, single abnormal IRP (>15mmHg) did not induce a higher IBC rate than normal LES relaxation (18.4% vs.14.2%, P>0.05). However, an IRP>15mmHg plus simultaneous contractions or large defects yielded 100% IBC. Hypercontractions (DCI>5000) induced a lower IBC rate than normal contractions (2.3% vs.12.7%, P<0.01) no matter IRP was abnormal or not. CONCLUSIONS: Certain esophageal motility abnormalities defined in Chicago Classification correlate with IBC; these include simultaneous contractions, large break and failed contractions. Small break may cause IBC in the proximal but not distal esophagus. Elevated DCI is not associated with IBC & actually seems to correspond with less transit disturbances than normal DCI. At least in this limited study IRP does not seem to correlate with bolus clearance in the context of intact peristalsis.

*: P value < 0.05. Correlation between HRM metrics and Eckardt score changes after POEM (P value)

Tu1175 High Resolution Manometry and Timed Barium Swallow Do Not Distinguish Patients With an Anatomical Esophageal Obstruction From a Functional Form of Esophageal Obstruction Steven B. Clayton, Rupal Patel, Joel Richter Background: High resolution manometry (HRM) has improved detection of esophageal dysmotilty and pathology of the lower esophageal sphincter (LES). On HRM, impaired deglutitive relaxation of LES with intact peristalsis has been termed esophagogastric junction outflow obstruction (EGOO). An anatomical esophageal obstruction or functional form of esophageal obstruction both can present with this manometric pattern. To our knowledge, no studies have examined esophageal metrics and timed barium swallow evaluations between patients with functional EGOO and a true anatomical esophageal outflow obstruction. Aim: The aim of this study was to identify patients with HRM characteristics of EGOO and to compare esophageal manometries and timed barium swallow evaluations (TBS) between patients with functional EGOO and a true anatomical esophageal obstruction. Methods: All HRM studies at the Joy McCann Culverhouse Swallowing Center were searched from November 2011 through November 2014. HRM meeting manometric criteria of EGOO were incorporated into the study. Manometric studies, endoscopic reports, and clinical records of patients were then analyzed in detail. TBS were performed in the upright position obtaining frontal spot X-rays of the esophagus at 1 and 5 minutes after ingestion of 250cc of lowdensity barium sulfate followed by administering a 13mm tablet and repeating frontal spot X-rays of the esophagus at 10 minutes. Results: 47 patients met the manometric criteria of EGOO. After a chart review, patients were categorized into anatomical obstruction if they had an identifiable esophageal obstruction or functional if no anatomical obstruction could be identified. Table 1 describes the demographic data for two groups. There were no significant differences between the two groups for any of the analyzed esophageal metrics or overall abnormalities identified on TBS (Table 2). Both groups had elevated intrabolus and basal LES pressures by the Chicago classification scale but there was no statistical significance between the two groups. Conclusion: The manometric diagnosis EGOO may include patients with an anatomical obstruction or functional form of esophageal obstruction. HRM and TBS do not distinguish the two groups. Therefore, mechanical causes should be excluded before functional EGOO is diagnosed and treated.

Δ: changes of score after POEM. *: P value < 0.05. Tu1173 The Effect of Weak and Failed Peristalsis on Postoperative Dysphagia Following Magnetic Sphincter Augmentation Raul J. Badillo, Kenneth R. DeVault, Steven P. Bowers, Dawn L. Francis Background: High resolution manometry (HRM) is performed prior to antireflux procedures for the purpose of excluding patients with major peristaltic abnormalities from an anti-reflux surgery that could worsen peristaltic function and lead to poor postoperative outcomes. The Chicago Classification categorizes peristaltic defects into those with intact, absent, frequent failed and weak peristalsis with large or small breaks. Due to unclear clinical significance, we sought to evaluate for dysphagia severity following magnetic sphincter augmentation with the LINX device in patients with weak and frequent failed peristalsis compared to those with intact peristalsis. Methods: We retrospectively reviewed esophageal manometry studies and GERD-HRQL Questionnaires of patients at our institution who received the LINX procedure (n=92, ages 18-86) from April 2012 to November 2014. Patients were previously asked to complete the GERD-HRQL Questionnaire both at baseline (prior to LINX) and at set post-operative intervals to objectively quantify ongoing reflux symptoms as well as the symptom of dysphagia (scored 0-5, with 0 reflecting absence of dysphagia and 5 reflecting incapacitating dysphagia). Only patients who received pre-operative HRM at our motility lab were included (n=39). Patients with spastic disorders which could contribute to the perception of dysphagia (1DES, 1 nutcracker, 1 jackhammer) were excluded, leaving 36 patients in the final analysis. Results: From a total of 36 patients, 19 had intact peristalsis and 17 had either weak peristalsis and/or frequent failed peristalsis. We compared

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regurgitation (P=0.048) and weight loss (P=0.000) in all achalasia patients. And it was correlated with weight loss in typeIachalasia (P=0.000). No correlation was found between Eckardt scores and other HRM metrics. Twenty-five patients (10 patients with type I and 15 patients with type II achalasia) were treated with POEM, and their total Eckardt scores and scores of each symptom were decreased after surgery (vs before POEM, all P<0.05). Eckardt scores changes (Eckardt scores before POEM minus Eckardt scores after POEM) were no difference between type I and type II achalasia. Eckardt scores and weight loss changes were positively correlated with IRP at baseline (all P<0.05). No correlation was found between other HRM metrics at baseline and Eckardt scores changes. Twelve patients (4 patients with type I and 8 patients with type II achalasia) underwent HRM after POME. IRP was changed significantly after POEM (vs before POEM, P=0.005), and so were DEP changes in type II achalasia (vs before POEM, P=0.010). IRP changes (IRP before POEM minus IRP after POEM) were positively correlated with Eckardt score changes (P=0.029). CONCLUSION: IRP correlates with symptoms and symptomatic outcomes of POEM in achalasia patients. HRM is an effective way to assess the severity of achalasia, and can be used to predict the efficacy of POEM. Correlation between HRM metrics and Eckardt scores at baseline (P value)