Digestive and Liver Disease - Volume 48 - Supplement 2 - February 2016

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e90 Abstracts of the 22nd National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231
OC.05.8
ESOPHAGO-GASTRIC JUNCTION MORPHOLOGY VARIABILITY
DURING STANDARD MANOMETRIC PROTOCOL AND AFTER
ESOPHAGEAL STIMULATION AND BODY CHANGE POSITION –
PRELIMINARY RESULTS
Della Coletta M.*1, Galeazzi F.1, Ioannou A.2, Torresan F.2,
Marabotto E.3, Zentilin P. 3, De Bortoli N.4, Surace L.4, Marchi S.4,
Ogliari C.5, Vecchi M. 5, Elvevi A.6 , Mauro A.6, Penagini R.6, Tolone S.7,
Savarino V.3, Savarino E.1
1Division of Gastroenterology, Department of Surgery, Oncology and
Gastroenterology, University of Padua, Padua, Italy, 2Gastroenterology
and Endoscopy Unit, Department of Medical and Surgical Sciences,
Policlinico Sant’ Orsola-Malpighi, University of Bologna, Bologna,
Italy, 3Division of Gastroenterology, Department of Internal Medicine,
University of Genoa, Genoa, Italy, 4Division of Gastroenterology,
Department of Internal Medicine, University of Pisa, Pisa, Italy,
5Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico
San Donato, Milano, Italy, 6Gastroenterology and Endoscopy Unit,
Department of Pathophysiology and Transplantation, Fondazione
IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Università degli
Studi di Milano, Milano, Italy, 7 Division of General and Bariatric
Surgery, Department of Surgery, Second University of Naples, Naples,
Italy
Background and aim: High-resolution manometry (HRM) provides
a better representation of the esophagogastric junction (EGJ)
isolating the crural diaphragm (CD) from the lower esophageal
sphincter (LES). According to the Chicago Classification (CC), three
different EGJ morphologic subtypes can be detected based on the
separation between the LES and the CD. However, few concerns have
been raised about the possibility to describe a dynamic structure
like the EGJ by a single snapshot taken at the beginning of the test.
Thus, we aimed to assess whether EGJ morphology may vary during
the standard manometric protocol and after esophageal stimulation
and body change position.
Material and methods: Consecutive patients with esophageal
symptoms presenting to different motility laboratories in Italy were
enrolled. Patients underwent a solid state HRM with the following
protocol: 5-min baseline recording after probe introduction, 10
single water swallows (WS, 5mL), 2 multiple rapid swallows (MRS,
five 2mL water swallows 2–3 s apart), change of body position
(seated) and multiple water swallow (MWS, 200mL of water using
‘multiple, rapid swallows’ without stopping). Tracings were analyzed
based on the CC and EGJ morphology was assessed after each step
as: Type I, no separation between the LES and the CD; Type II,
minimal separation (>1 and <2 cm); Type III, >2 cm of separation. In
case of reflux symptoms, patients also underwent pH(-impedance)
testing off-therapy [abnormal if acid exposure time higher than 4.2%
or number of reflux episodes greater than 54 or positive symptom-
reflux association using symptom association probability (SAP+ if
≥95%) and symptom index (SI+ if ≥50%)].
Results: We enrolled 52 [23M/29F; mean age 52 (17-82); mean BMI
24 (17-35)] consecutive outpatients. Based on CC, we identified
32 (62%) patients with EGJ Type I, 8 (15%) with EGJ Type II and 4
(8%) with EGJ Type III, in whom no EGJ changes occurred during
standard manometric protocol or after esophageal stimulation or
body change position. In contrast, we identified 8 (15%) patients
in whom EGJ morphology varied after WS (n=3), MWS (n=3), body
change position (n=1) or MWS (n=3). In particular, in 2 patients
there was more than one change. All patients with EGJ variation
who underwent pH-(impedance) monitoring had an abnormal test
(5/5, 100%), whereas this phenomenon occurred only in 13 out of 25
(52%) patients with stable EGJ (p=0.0657). Endoscopy did not vary
between the two groups [abnormal in 2/8 (25%) with changed EGJ
vs. 8/44 (18%) with stable EGJ, p=06415].
Conclusions: Esophago-gastric junction morphology varies only
in a minority of patients, suggesting that the single assessment
at the beginning of the test has a high per patient reproducibility.
On the other hand, EGJ changes occurring during HRM testing are
associated with more objective evidence of GERD, thus confirming
the major role of EGJ as anti-reflux barrier.
OC.05.9
LONG VS SHORT POEM FOR THE TREATMENT OF ACHALASIA.
INTERIM ANALYSIS OF A RANDOMIZED CONTROLLED TRIAL
Familiari P.*, Cali’ A., Landi R., Gigante G., Boskoski I., Santiago A.Z.,
Greco S., Barbaro F., Tringali A., Perri V., Costamagna G.
Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
Background and aim: The use of Per-Oral Endoscopic Myotomy
(POEM) for the treatment of achalasia has been increasing in the
last years. However, some technical issues remain to be defined. In
the published series a long myotomy (12cm) was usually performed.
Surgical myotomy is typically shorter, being protracted for about
8cm.
We report on the interim analysis of a randomized controlled trial
that evaluates the outcomes of POEM according to the length of the
myotomy.
Material and methods: Patients with type I and type II achalasia
were randomly assigned to one of the two study groups, long-
myotomy (LM) and short-myotomy (SM).
Patients in the LM-group received a 13cm-long POEM (including 3cm
on the stomach); in the SM-group patients received POEM extended
for 8 cm (including 3cm on the stomach). During follow-up, HRM,
pH-study and EGD were regularly performed and symptoms
assessed with the use of the Eckardt score (ECK).
Study outcomes were clinical success (ECK <4), variation of LES
pressure, procedure time, prevalence of complications and GERD.
The main hypothesis was that the results of a SM are not inferior
to the results of a LM (non-inferiority trial). Calculated sample size
was 200 patients. Study was approved by the IRB of the Gemelli
University Hospital.
Results: Until today, 73 patients were enrolled, 38 in the LM- and 35
in the SM-group. Mean age of patients, gender, achalasia type, mean
LES pressure, preoperative ECK, symptoms duration and previous
treatments were similar in both groups. POEM was technically
successful in all the cases. Procedure time was significantly longer
in the LM-group compared to the SM-group (59.2±16.7 minutes vs
47.7±13.2 min, p=0.0018).
A total of 49 patients completed a minimum 6-month follow-up
(23 in LM- and 26 in SM-group, mean follow-up 8 months). Clinical
success was 100% in both groups. Postoperative ECK (0.5±0.8 vs
0.5±0.8, p=ns) and prevalence of GERD (42.9% vs 65%, p=ns) were
similar in the LM- and SM-groups, respectively. LES pressure
(17±9.7 mmHg vs 11.4±6.5 mmHg, p=0.02) and 4sIRP (8.6±4.9
mmHg vs 5.9±5.0 mmHg, p=0.06) were lower in the SM-group. No
complications occurred, and a similar prevalence of mild procedural
adverse events was reported.
Conclusions: This interim analysis demonstrates the feasibility
of the study, and the safety and the efficacy of the investigational
technique (SM). With the limits of an interim analysis, with a very
short follow up, the main hypothesis is confirmed.