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The Value of Timed Barium Esophagram in Achalasia after Myotomy

Stefan S Kachala, MD1, Prashanthi Thota, MD2, Jeevanatham Rajeswaran, PhD3, Usman Ahmad, MD1, Daniel Raymond, MD1, A Zanoni, MD4, Sudish Murthy, MD, PhD1, Thomas Rice, MD1, Mark Baker, MD5, Scott Gabbard, MD2, Eugene Blackstone, MD1, Siva Raja, MD, PhD1. 1Cleveland Clinic Department of Thoracic and Cardiovascular Surgery, 2Cleveland Clinic Department of Gastroenterology and Hepatology, 3Cleveland Clinic Department of Quantitative Health Sciences, 4Univeristy of Verona, Italy, 5Cleveland Clinic Department of Diagnostic Radiology

INTRODUCTION: Patients with achalasia may require re-intervention after Heller myotomy despite initial palliation. Because symptoms poorly correlate with esophageal function, we employ Timed Barium Esophagram (TBE), a validated tool to assess esophageal emptying. Our objectives to elucidate the value of TBE after myotomy were: 1) to determine the longitudinal trends of TBE in achalasia patients post myotomy and 2) identify perioperative factors that modulate TBE trends.

METHODS AND PROCEDURES: From 3/1995 to 4/2013, 635 patients underwent Heller myotomy as a treatment for achalasia, of which 596 had preoperative and longitudinal TBE’s. Mean age was 49 years, 54% were men. A TBE was performed at regular follow up of 1-2 year intervals after surgery. We assessed the temporal trend of barium volume at 1 minute. A non-linear mixed effects regression model estimated the shaping parameter at each phase to generate a curve and to identify factors associated with the TBE trends.

RESULTS: After surgery, the volume of barium at 1 minute decreased from 122 ml to 51 ml. A total of 83 patients underwent additional re-intervention. The risk of re-intervention at 1-month, 1-year, 5 years, and 10 years are 1%, 5%, 14%, and 18% respectively. TBE revealed temporal trends in volume between groups that had eventual re-intervention and those with a durable response (figure). 513 patients (86%) had a durable response with decreasing retained barium volume over time. Clinical factors associated with higher levels of retained barium at 1 minute included older age (P=.02) and larger BMI (P=.04), while Dor fundoplication was associated with less retained barium (P=.0006) as compared with other methods.

CONCLUSIONS: TBE is easily implemented, inexpensive, and well tolerated by patients. We recommend TBE to longitudinally evaluate esophageal function post myotomy, as patients may require additional therapy for palliation.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 80072

Program Number: S094

Presentation Session: Foregut 2

Presentation Type: Podium

50

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