Division of Gastroenterology and Digestive Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy.
Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Neurogastroenterol Motil. 2023 Jul;35(7):e14552. doi: 10.1111/nmo.14552. Epub 2023 Feb 21.
Panesophageal pressurization (PEP) defines type II achalasia on high-resolution-manometry (HRM) but some patients exhibit spasm after treatment. The Chicago Classification (CC) v4.0 proposed high PEP values as predictor of embedded spasm, yet supportive evidence is lacking.
Fifty seven type II achalasia patients (47 ± 18 years, 54% males) with HRM and LIP Panometry before and after treatment were retrospectively identified. Baseline HRM and FLIP studies were analyzed to identify factors associated with post-treatment spasm, defined on HRM per CC v4.0.
Seven patients (12%) had spasm following treatment (peroral endoscopic myotomy 47%; pneumatic dilation [PD] 37%; laparoscopic Heller myotomy 16%). At baseline, greater median maximum PEP pressure (MaxPEP) values on HRM (77 vs 55 mmHg, p = 0.045) and spastic-reactive contractile response pattern on FLIP (43% vs 8%, p = 0.033) were more common in patients with post-treatment spasm while absent contractile response on FLIP was more common in patients without spasm (14% vs 66%, p = 0.014). The strongest predictor of post-treatment spasm was the percentage of swallows with MaxPEP ≥70 mmHg (best cut-off: ≥30%), with AUROC of 0.78. A combination of MaxPEP <70 mmHg and FLIP 60 mL pressure < 40 mmHg identified patients with lower rates of post-treatment spasm (3% overall, 0% post-PD) compared to those with values above these thresholds (33% overall, 83% post-PD).
High maximum PEP values, high FLIP 60 mL pressures and contractile response pattern on FLIP Panometry prior to treatment identified type II achalasia patients more likely to exhibit post-treatment spasm. Evaluating these features may guide personalized patient management.
食管全段测压（PEP）定义 HRM 下的 II 型贲门失弛缓症，但部分患者治疗后出现痉挛。芝加哥分类（CC）v4.0 提出高 PEP 值是嵌入性痉挛的预测因子，但缺乏支持证据。
回顾性分析 57 例 HRM 和 LIP 测压仪检查证实的贲门失弛缓症 II 型患者（47±18 岁，54%为男性）的治疗前后资料。分析基线 HRM 和 FLIP 研究，以确定与治疗后痉挛相关的因素，痉挛的定义是根据 CC v4.0 的 HRM 标准。
7 例（12%）患者治疗后出现痉挛（经口内镜肌切开术 47%；气囊扩张术 37%；腹腔镜 Heller 肌切开术 16%）。基线时，HRM 上更高的中位最大 PEP 压力（MaxPEP）值（77 比 55mmHg，p=0.045）和 FLIP 上痉挛反应性收缩模式（43%比 8%，p=0.033）更常见于治疗后发生痉挛的患者，而无痉挛的患者 FLIP 上无收缩反应（14%比 66%，p=0.014）更常见。治疗后痉挛的最强预测因素是吞咽时最大 PEP 值≥70mmHg 的百分比（最佳截断值：≥30%），其 AUC 为 0.78。MaxPEP＜70mmHg 和 FLIP 60mL 压力＜40mmHg 的组合可以识别出治疗后痉挛发生率较低的患者（总体 3%，气囊扩张术 0%；总体 0%，腹腔镜 Heller 肌切开术），而这些阈值以上的患者（总体 33%，气囊扩张术 83%）痉挛发生率较高。
高最大 PEP 值、高 FLIP 60mL 压力和治疗前 FLIP 测压的收缩反应模式可以识别出更有可能出现治疗后痉挛的 II 型贲门失弛缓症患者。评估这些特征可能有助于指导患者的个体化管理。
