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

Recurrent dysphagia after myotomy is multifactorial and challenging to classify. Although high-resolution manometry (HRM), functional lumen imaging probe (FLIP), and contrast studies are widely used, no standardized framework integrates anatomic and physiologic findings in the post-myotomy setting. The Atlanta Consortium for Targeted Interventions in Oesophageal and Foregut Non-Malignant Disorders (ACTION) conducted a two-part study to evaluate inter-rater agreement among experts on mechanisms of recurrent dysphagia and develop early consensus using a modified Delphi process.

In Part 1, six achalasia experts independently reviewed 42 anonymized cases of recurrent post-myotomy dysphagia and assigned a primary failure mechanism from eight prespecified categories. Inter-rater agreement was measured using Fleiss' kappa. Physiologic measures including integrated relaxation pressure (IRP), distensibility index (DI), and maximum intra-bag FLIP pressure were compared across agreement tiers. Findings informed consensus statement development for Part 2, during which an expanded panel of 13 experts completed a two-round modified Delphi process. Round 1 involved rating 12 statements on a 5-point Likert scale. Consensus required a mean ≥ 4 with ≥ 80% agreement. Round 2 included structured discussion, revision, and re-rating of statements.

Among 42 cases (mean age 53.7 years; 57% female), the index intervention was Heller myotomy in 76%, POEM in 10%, and pneumatic dilation in 14% of cases. Diagnostic agreement was fair (Fleiss' κ = 0.25). Although high-agreement cases showed slightly lower median IRP and DI, distributions were broad and not statistically different, indicating that physiologic thresholds alone do not determine expert interpretation. After two rounds, the Delphi process resulted in 13 of 15 statements achieving consensus, emphasizing an anatomy-first framework with physiologic data interpreted in structural context.

Significant variability exists in expert assessment of post-myotomy dysphagia. This study establishes early consensus on key failure mechanisms of myotomy failure and provides reproducible anatomic subtypes to support standardized diagnostic pathways.