title: Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes.
abstract: BACKGROUND
  Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy-Heller myotomy (HM)-is employed.
  
  
  METHODS
  Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20 % swallows; subtype III: premature contractions in ≥20 % swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0 = no symptoms, 4 = severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes.
  
  
  RESULTS
  Sixty achalasia subjects (56.1 ± 2.4 years, 55 % female) fulfilled inclusion criteria, 15 % with subtype I, 58 % with subtype II, and 27 % with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85 %, liquids: 73 %), regurgitation (84 %), and chest pain (35 %); mean GSS was 7.1 ± 0.3. Upon follow-up 2.1 ± 0.2 years after HM, GSS declined to 1.9 ± 0.4 (p < 0.001), with surgical satisfaction score of 8.7 ± 0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender (p = 0.003) and dysphagia for liquids (p = 0.043) remained predictive on multivariate analysis.
  
  
  CONCLUSIONS
  When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA.
authors.forename: Amit
authors.initials: A
authors.lastname: Patel
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA.
authors.forename: Ami
authors.initials: A
authors.lastname: Patel
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA.
authors.forename: Faiz A
authors.initials: FA
authors.lastname: Mirza
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA.
authors.forename: Samad
authors.initials: S
authors.lastname: Soudagar
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA.
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Sayuk
authors.affiliation: Division of Gastroenterology, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8124, St. Louis, MO, 63110, USA. cprakash@wustl.edu.
authors.forename: C Prakash
authors.initials: CP
authors.lastname: Gyawali
mesh_terms: D016208:Databases, Factual; D003680:Deglutition Disorders / Q000209:etiology; D004931:Esophageal Achalasia / Q000150:complications / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004945:Esophagoscopy; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000209:etiology; D008297:Male; D008365:Manometry; D008875:Middle Aged; D017060:Patient Satisfaction; D011446:Prospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: Achalasia; Heller myotomy; High-resolution manometry