Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenker's diverticulum.

BACKGROUND AND AIMS: Flexible endoscopic cricopharyngeal myotomy (FECM) allows minimally invasive treatment of patients with Zenker's diverticulum (ZD); however, retreatment rates are substantial. We hypothesized that the functional lumen imaging probe (FLIP) may provide insight into ZD pathophysiology and serve as an intraprocedural guide to adequacy of myotomy. METHODS: We prospectively evaluated 11 ZD patients undergoing FECM and compared the baseline cricopharyngeal (CP) distensibility with 16 control subjects. Intraprocedural CP distensibility was measured immediately pre- and postmyotomy. The CP distensibility index (CP-DI) was defined as a ratio of the narrowest cross-sectional area (nCSA) and the corresponding intrabag pressure at 40 mL distension. Same-procedure myotomy extension was undertaken in a subgroup if threshold distensibility changes were not met. RESULTS: ZD patients had reduced baseline nCSA and CP-DI compared with control subjects, (169.6 vs 227.5 mm2 [P < .001] and 3.8 vs 7.6 mm2/mm Hg [P < .001], respectively). After CP myotomy, both nCSA and CP-DI increased significantly by an average of 74.2 mm2 (95% confidence interval [CI], 35.1-113.3; P = .002) and 2.2 mm2/mm Hg (95% CI, .6-3.8; P = .01), respectively. In the subgroup with no significant change in CP distensibility after initial myotomy (n = 6), myotomy extension resulted in significant increases in both mean nCSA and CP-DI of 66.6 mm2 (95% CI, 16.4-116.8; P = .03) and 1.9 mm2/mm Hg (95% CI, .4-3.3; P = .015), respectively. There were no adverse events. CONCLUSIONS: CP distensibility is reduced in ZD patients and is partially reversible by FECM. An intraprocedural FLIP CP distensibility measurement is safe and sensitive in detecting myotomy-induced changes. These findings support using FLIP to optimize FECM outcome. Further studies are required to derive precise metrics predictive of clinical response.

Intermittent dysphagia for solids associated with a multiringed esophagus: clinical features and response to dilatation.

The entity of the multiringed esophagus, generally presenting in adults as intermittent dysphagia for solids, is relatively uncommon and its pathogenesis is unknown. The goal of this study was to describe the demographic, clinical, and endoscopic features of patients presenting with this condition, their response to esophageal dilatation, and the relationship of multiple esophageal rings to eosinophilic esophagitis. Between 1989 and June 2004, 32 patients at this adult hospital fulfilled the following inclusion criteria: (1) intermittent dysphagia for solids, (2) multiple esophageal rings at endoscopy, and (3) esophageal dilatation(s) performed. Response to esophageal dilatation was measured by need for subsequent dilatations. Seventy-five percent of the patients were male. Median age at onset of dysphagia was 21 years and at presentation 36.5 years. All had multiple rings in the proximal or midesophagus on endoscopy and had undergone a total of 73 esophageal dilatations with no esophageal perforations. Median maximal dilator size was 15 mm; however, 16% developed significant esophageal mucosal tears even with 11-mm dilators. Sixty-six percent required repeat dilatation, with the median time interval before recurrence being 8 months. Eosinophilic esophagitis (mucosal eosinophil count > 20/HPF) was present in 50% of this cohort. From this study we conclude that a multiringed esophagus causing intermittent dysphagia occurs predominantly in young males, responds well to dilatation, but repeated dilatations are often necessary. Dilatation can lead to extensive mucosal tears and should be performed with caution. Eosinophilic esophagitis is commonly but not invariably associated with this entity. Frequent relapse of dysphagia highlights the need for effective pharmacotherapy.