The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia.
BACKGROUND
A new manometric classification of esophageal achalasia has recently been proposed that also suggests a correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of achalasia patients undergoing laparoscopic Heller-Dor myotomy.


METHODS
We evaluated 246 consecutive achalasia patients who underwent surgery as their first treatment from 2001 to 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored and barium swallow X-ray, endoscopy, and esophageal manometry were performed before and again at 6 months after surgery. Patients were divided into three groups: (I) no distal esophageal pressurization (contraction wave amplitude <30 mmHg); (II) rapidly propagating compartmentalized pressurization (panesophageal pressurization >30 mmHg); and (III) rapidly propagating pressurization attributable to spastic contractions. Treatment failure was defined as a postoperative symptom score greater than the 10th percentile of the preoperative score (i.e., >7).


RESULTS
Type III achalasia coincided with a longer overall lower esophageal sphincter (LES) length, a lower symptom score, and a smaller esophageal diameter. Treatment failure rates differed significantly in the three groups: I = 14.6% (14/96), II = 4.7% (6/127), and III = 30.4% (7/23; p = 0.0007). At univariate analysis, the manometric pattern, a low LES resting pressure, and a high chest pain score were the only factors predicting treatment failure. At multivariate analysis, the manometric pattern and a LES resting pressure <30 mmHg predicted a negative outcome.


CONCLUSIONS
This is the first study by a surgical group to assess the outcome of surgery in 3 manometric achalasia subtypes: patients with panesophageal pressurization have the best outcome after laparoscopic Heller-Dor myotomy.
Salvador
Renato
R
Department of Surgical and Gastroenterological Sciences, Clinica Chirurgica I, School of Medicine, University of Padova, Padova, Italy.
Costantini
Mario
M
Zaninotto
Giovanni
G
Morbin
Tiziana
T
Rizzetto
Christian
C
Zanatta
Lisa
L
Ceolin
Martina
M
Finotti
Elena
E
Nicoletti
Loredana
L
Da Dalt
Gianfranco
G
Cavallin
Francesco
F
Ancona
Ermanno
E
D000328:Adult; D004931:Esophageal Achalasia / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000473:pathology / Q000503:physiopathology; D004947:Esophagus / Q000473:pathology / Q000503:physiopathology; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D016896:Treatment Outcome