Developing consensus in post-myotomy dysphagia: a Delphi study integrating anatomic and physiologic assessment from...

Area of Science:

• Gastroenterology
• Esophageal Disorders
• Surgical Outcomes

Background:

• Recurrent dysphagia post-myotomy presents diagnostic challenges due to multifactorial causes.
• Current diagnostic tools like HRM, FLIP, and contrast studies lack a standardized framework for integrating findings.
• The ACTION consortium aimed to address this gap in post-myotomy dysphagia assessment.

Purpose of the Study:

• To evaluate inter-rater agreement among experts on the mechanisms of recurrent dysphagia after esophageal myotomy.
• To develop an early consensus on a standardized diagnostic framework for post-myotomy dysphagia using a modified Delphi process.

Main Methods:

• Part 1: Six experts assessed 42 anonymized cases, assigning failure mechanisms and measuring inter-rater agreement (Fleiss' kappa).
• Physiologic data (IRP, DI) were analyzed across agreement levels.
• Part 2: A modified Delphi process with 13 experts refined consensus statements over two rounds.

Main Results:

• Fair inter-rater agreement (κ=0.25) was observed in initial case reviews.
• Physiologic measures alone did not consistently predict expert interpretation.
• A consensus was reached on 13 of 15 statements, advocating an anatomy-first approach with context-dependent physiologic data interpretation.

Conclusions:

• Significant variability exists in expert assessment of post-myotomy dysphagia.
• The study established early consensus on key myotomy failure mechanisms.
• Reproducible anatomic subtypes were identified to support standardized diagnostic pathways for post-myotomy dysphagia.