BACKGROUND & AIMS:Achalasia appears to increase the risk of esophageal squamous cell carcinoma, but existing evidence relies on small studies that did not adjust for this cancer's main risk factors (ie, smoking and alcohol overconsumption). Whether achalasia increases the risk of esophageal adenocarcinoma, whose main risk factor is gastroesophageal reflux disease (GERD), is even more uncertain. This study aimed to clarify these associations. METHODS:A population-based case-control study was conducted in 5 Nordic countries from 1987 to 2023. Esophageal cancer cases (n = 35,604) were matched to 10 times as many background population controls by age, sex, calendar year, and country (n = 355,869). Conditional logistic regression provided odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for smoking and alcohol, and additionally for GERD in a mechanistic model. All variables came from national health data registries. RESULTS:Achalasia was present in 137 cases (96 squamous cell carcinomas and 41 adenocarcinomas) and 230 controls (99 squamous cell carcinomas and 131 adenocarcinomas). Achalasia was associated with a strongly increased risk of esophageal squamous cell carcinoma (OR, 9.46; 95% CI, 7.07-12.65). A moderate association was found for esophageal adenocarcinoma (OR, 3.05; 95% CI, 2.14-4.35), which attenuated after adjustment for GERD (OR, 1.44; 95% CI, 0.99-2.09). Achalasia treated with myotomy or dilation was associated with an even stronger association with esophageal squamous cell carcinoma (OR, 16.33; 95% CI, 11.26-23.67), but not with esophageal adenocarcinoma after adjustment for GERD (OR, 1.32; 95% CI, 0.76-2.30). CONCLUSIONS:Achalasia appears strongly and independently associated with esophageal squamous cell carcinoma. The association with esophageal adenocarcinoma is less strong and seems to be largely explained by GERD.

BACKGROUND:During endoscopy, which often is the initial diagnostic test performed for esophageal symptoms, a CARS endoscopic score can be calculated and functional lumen imaging probe (FLIP) panometry can be performed. Recently, the combination of a CARS score > 4 calculated from endoscopic videos and non-spastic obstruction on FLIP noted from offline analysis has been found to be highly predictive of disorders of EGJ outflow obstruction (i.e., achalasia and conclusive EGJOO). We aimed to validate these findings based on detailed assessments performed in real time during endoscopy and FLIP panometry with reclassification based on the CARS score and Dallas Consensus for FLIP panometry. METHODS:We reviewed our clinical database to identify patients who had endoscopy with documentation of an esophageal motility examination (i.e., components of the CARS score and FLIP with documented EGJ-diameter/distensibility, contractile response pattern at each volume) and HRM performed at our Center for Esophageal Diseases. CARS scores were calculated from score components documented in the endoscopy report and FLIP panometry classifications were reclassified according to the Dallas Consensus. Manometric diagnosis was based on Chicago Classification v4.0 (CCv4.0). KEY RESULTS:In 120 patients (mean age 55.5 years, 66% female), the combination of CARS score ≥ 4 and reduced EGJ opening (REO) on FLIP was highly suggestive of an EGJ obstruction diagnosis (achalasia or conclusive EGJOO) with 100% specificity and 100% positive predictive value. CONCLUSIONS:A CARS score ≥ 4 combined with FLIP-REO obtained in real time during endoscopy is highly predictive of an EGJ obstruction diagnosis (achalasia or confirmed EGJOO) on HRM.

BACKGROUND:Functional lumen imaging probe (FLIP) panometry assesses esophageal motility during sedated endoscopy. Recently, the FLIP panometry motility classification was refined (v2.0) in the Dallas Consensus. This study aimed to characterize esophageal motility using the FLIP v2.0 classification scheme and compare its classifications with those of FLIP v1.0 and high-resolution manometry (HRM) diagnoses on the basis of Chicago Classification v4.0 (CCv4.0). METHODS:805 adult patients who completed both FLIP and HRM at two tertiary esophageal centers were included; 704 with conclusive CCv4.0 diagnoses comprised the primary analysis, and 101 with inconclusive CCv4.0 diagnoses were also described. Esophagogastric junction (EGJ) opening and contractile response (CR) patterns were evaluated using 16-cm FLIP during sedated endoscopy, with motility classifications defined by FLIP v1.0 and v2.0 criteria. HRM was classified per CCv4.0. RESULTS:In the primary analysis, among the 137 (19%) patients with normal motility on FLIP panometry, 93% had normal motility or ineffective esophageal motility (IEM) on HRM. Normal motility on FLIP panometry had a 99% negative predictive value for disorders of EGJ outflow. Among the 163 (23%) patients with non-spastic obstruction (defined by reduced EGJ opening and absent/diminished CR) on FLIP panometry, 91% had a conclusive disorder of EGJ outflow on HRM. Among the 37 patients with type III achalasia on HRM, 16 (43%) were classified as spastic obstruction on FLIP panometry. CONCLUSIONS:FLIP panometry v2.0 categorized esophageal motility in a manner that frequently paralleled the HRM/CCv4.0 diagnoses. FLIP panometry offers a well-tolerated approach that complements, or may be an alternative to, HRM for diagnosing esophageal motility disorders.

BACKGROUND:During pre-bariatric surgery evaluation, we routinely perform objective testing for GERD (endoscopy, pH monitoring if no reflux esophagitis found) with high-resolution manometry (HRM) and functional lumen imaging probe (FLIP) to evaluate esophageal motility. In this study, we aimed to identify differences in FLIP metrics between obese patients with and without GERD. METHODS:We reviewed our clinical database of obese patients evaluated for bariatric surgery, including surgery-naïve patients and patients who had sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) that resulted in inadequate weight loss. We recorded GERD symptoms, HRM findings, and FLIP metrics (EGJ-diameter, distensibility index, and contractile response patterns). Patients with reflux esophagitis or acid exposure time (AET) > 6% were considered GERD+; those with AET ≤ 6% were deemed GERD. KEY RESULTS:We included 160 patients (mean age 50.2 ± 12.4 years; 79% women; 66 surgery-naïve) (29 GERD-, 37 GERD+), 70 SG (20 GERD-, 50 GERD+), 24 RYGB (16 GERD-, 8 GERD+). FLIP abnormalities were frequent, including reduced EGJ opening (REO) (12.1% surgery-naïve, 14.3% SG, 12.5% RYGB) and abnormal contractile response (59.1% surgery-naïve, 71.4% SG, 62.5% RYGB). FLIP differences were found between GERD+ and GERD- patients: REO (8.0% vs. 30.0%, p = 0.02) and BCR (2.0% vs. 15.0%, p = 0.02) were both less frequent in GERD+ than in GERD- SG patients. SRCR was more frequent in GERD- than in GERD+ surgery-naïve patients (31.0% vs. 5.4%, p = 0.01). CONCLUSIONS:While FLIP differences between GERD- and GERD+ patients exist, there were no FLIP metrics that clearly predicted GERD in obese patients either before or after bariatric surgery.

BACKGROUND & AIMS:Functional lumen imaging probe (FLIP) panometry provides assessment of the esophagogastric junction opening and esophageal body contractile activity during an endoscopic procedure and is increasingly being incorporated into comprehensive esophageal motility assessments. The aim of this study was to provide a standardized approach and vocabulary to the procedure and interpretation and update the motility classification scheme. METHODS:A working group of 19 FLIP panometry experts convened in a modified Delphi consensus process to produce and assess statements on the FLIP panometry procedure and interpretation. Three rounds of voting were conducted on an agreement scale of 1-9 for appropriateness, followed by face-to-face discussions and an opportunity for revisions of statements. The "percent agreement" was the proportion of votes with score ≥7 indicating level of agreement on appropriateness. RESULTS:A total of 40 statements were selected for final inclusion in the Dallas Consensus, including FLIP panometry protocol, interpretation of esophagogastric junction opening and contractile response, and motility classification scheme. Key statements included: "FLIP panometry should be interpreted in the context of the clinical presentation, the accompanying EGD [esophagogastroduodenoscopy] findings and other relevant complementary testing" (median response 9.0; 100% agreement). "A major motor disorder is unlikely in the setting of a 'normal' FLIP panometry classification" (median response 9.0; 94% agreement). "Diminished or absent contractile response with reduced esophageal opening (ie, nonspastic obstruction) supports the diagnosis of a disorder of EGJ [esophagogastric junction] outflow" (median response 8.5; 94% agreement). CONCLUSIONS:The standardized approach for performance and interpretation of the Dallas Consensus can facilitate use of FLIP panometry in broad clinical settings.

We recently developed the CARS score, an endoscopic scoring system for achalasia that is based on four common endoscopic findings of the disease (i.e., esophageal Contents, Anatomy, Resistance at the LES, and Stasis). We have shown that the CARS score performs well in predicting the presence of achalasia. Now, we aimed to find whether the CARS score improves after treatment of achalasia or EGJ outflow obstruction (EGJOO) with peroral endoscopic myotomy (POEM). We reviewed our Center for Esophageal Diseases clinical database for patients who had POEM performed for treatment of achalasia or EGJ outflow obstruction between January 2020 and December 2022. Such patients underwent a comprehensive work up for their motility disorders including endoscopy with calculation of CARS score before and after POEM. Patients with suspected or known achalasia were instructed to be on a 1–5 day liquid diet prior to their endoscopic procedures. Eighty nine patients treated with POEM meet inclusion criteria; 74 patients had achalasia (9 type 1, 46 type 2, 19 type 3), and 15 had EGJOO. The CARS score decreased significantly after POEM (3.5 vs 1.7, p < 0.01). Subset analyses of CARS subscores revealed significant reductions in contents (mean reduction 0.25, p < 0.05), resistance at the LES (mean reduction 1.3, p < 0.01) and stasis (mean reduction 0.3, p < 0.01). Patients with Type 1/2 achalasia had improvement in all CARS subscores whereas those with EGJOO/Type 3 achalasia had improvement primarily in LES resistance. We found significant reductions in the endoscopic CARS score in patients treated with POEM. Reductions in total CARS scores were driven primarily by improvements in the endoscopic assessment of Contents, Resistance-LES and Stasis subscores. Improvement in CARS subscores appear to differ depending on HRM diagnosis. Further studies are needed to determine whether improvement in the CARS score.

Background: Suppression of gastric acid secretion with proton pump inhibitors (PPIs) has been the mainstay of medical treatment for gastroesophageal reflux disease (GERD) for more than 30 years. Members of a newer class of medication, the potassium-competitive acid blockers (P-CABs), can inhibit gastric acid production faster, longer, and more potently than PPIs. In November 2023, vonoprazan became the first P-CAB to receive FDA approval for GERD treatment. Methods: The American Foregut Society (AFS) convened a 13-member panel of expert gastroenterologists and foregut surgeons to produce a white paper report on how clinicians might use P-CABs to treat GERD. After conducting a comprehensive literature review, panelists proposed 20 total statements on key aspects of P-CAB pharmacokinetics, use of P-CABs for erosive esophagitis and non-erosive reflux disease, and P-CAB safety, as well as 13 recommendation statements on how to use a P-CAB in clinical practice. Using RAND/UCLA Appropriateness Methodology, panelists independently voted to rank each statement for appropriateness, and, after panel review and discussion of first-round voting results, statements were accepted, discarded, or modified for a final round of voting. Results: Twenty-three statements were finally accepted (3 on P-CAB pharmacokinetics, 5 on P-CABs for erosive esophagitis, 3 on P-CABs for non-erosive reflux disease, 4 on P-CAB safety, 8 on how to use P-CABs in clinical practice). Conclusions: This AFS white paper report provides the statements accepted by the expert panel on the use of P-CABs in the treatment of GERD, and summarizes the literature review that provided the rationale for those statements.

INTRODUCTION:Functional lumen imaging probe (FLIP) planimetry performed during peroral endoscopic myotomy (POEM) evaluates esophagogastric junction (EGJ) metrics. The 16 cm FLIP catheter allows for topographical assessment of the esophageal body, and previous intraoperative studies have only utilized the 8 cm catheter or combined data from both catheters. Our aim was to characterize the utility of the 16 cm catheter during POEM with respect to intraoperative tailoring of the myotomy length and intermediate outcomes after POEM. METHODS:We conducted a retrospective review of procedural and follow-up information of consecutive patients who underwent POEM with an intraoperative 16 cm catheter between January 2020 and September 2023. RESULTS:In 100 patients with intraoperative FLIP, the mean myotomy length was 8.2 cm. A tailored short myotomy (≤ 4 cm) using FLIP was performed in 10% of cases with comparable outcomes in LES obstruction and GERD metrics compared to > 4 cm myotomy length. On the basis of topographical FLIP findings, the myotomy was extended to capture spastic body features in 32% of cases including Type 2 achalasia (5), epiphrenic diverticulum (3) and prior myotomy (10). In intervention-naive patients, 70.5% achieved clinical success (Eckardt ≤ 3) at median follow-up of 30.9 months (IQR 6.5-40.9 months) with improvement in LES obstruction and GERD metrics among the intermediate follow-up cohort. An intraoperative post-myotomy EGJ diameter of ≥ 16 mm was associated with a lower rate of repeat intervention (2 vs. 5 patients, p = 0.038) and not associated with increased reflux outcomes. CONCLUSION:Intraoperative FLIP using the 16 cm catheter during POEM enables a tailored myotomy guided by both EGJ metrics and topographical assessment.