Do outcomes of surgical treatment for Achalasia depend on the manometric subtype?

Keliang Xiao1, Oscar Crespin2

Roger Tatum2, Ana V. Martin2,Saurabh Khandelwal2, Brant Oelschlager2, Carlos Pellegrini2

UMKC School of Medicine1, University of Washington School of Medicine2

Introduction• High Resolution Manometry (HRM) yields

better understanding of esophageal motility than does conventional manometry, and a new classification system which describes three distinct HRM subtypes of achalasia based on esophageal body contraction patterns appears to be a promising tool in predicting results of treatment with standard Heller Myotomy.

• The aim of this study is to analyze the outcomes of surgical treatment with extended Heller myotomy for each subtype and to identify additional parameters that may predict success of therapy.

Methods• From 2008 to 2013 at the University of

Washington Medical Center• 72 patients underwent laparoscopic extended

Heller myotomy for first time. • In addition to manometric parameters, clinical

records were reviewed for symptom duration, patient age at the time of referral, and preoperative esophageal dilation (stage I-III) as assessed by radiography.

• We defined treatment failure as no improvement in symptoms and/or need for a second therapy within one year after the operation.

• Long term follow up data (15 to 46 months) was available for a subset of 25 patients in the form of a survey evaluating overall satisfaction with the operation.

Results• The 72 myotomy patients included 13 with type I (no

contractions), 54 with type II (pan-esophageal pressurizations), and 5 with type III (high-amplitude distal spasm).

• Failure was found in 1 patient with manometric type I and radiologic stage III esophageal dilation, 1 patient with manometric type II and radiologic stage II esophageal dilation, and none with manometric type III .

• All of the type I patients had at least some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group.

• Treatment failure was not observed in any of the patients under 50 years old (n=35) nor in any patients with stage I esophageal dilation.

• Only one of the 25 patients with long term follow up reported dissatisfaction with the treatment result; this patient had type II achalasia on HRM and esophageal dilation was stage I.

Conclusion• Overall, laparoscopic extended Heller myotomy

is a highly successful treatment for patients with achalasia, and outcomes do not appear to vary significantly according to HRM subtype.

• Stage I esophageal dilation and age below 50 may be better indicators of consistent symptom relief after surgical therapy for this disease.

References1. Rohof, WO. Et al, “Outcomes of Treatment for

Achalasia Depend on Manometric Subtype." Gastroenterology 144.4 (2013): 718-25.

2. Pandolfino, JE, et al "Achalasia: A New Clinically Relevant Classification by High-Resolution Manometry." Gastroenterology 135.5 (2008): 1526-33.

Figure 1. Outcome by Manometric Subtype1 2 3

0.00

0.20

0.40

0.60

0.80

1.00

1.20

0.92 0.98 1.00

0.08 0.02 0.00

Failure rates by Subtypes

Stage I Stage II Stage III0

102030405060708090

100100

94

71

06

29

SuccessFailure

Figure 2. Outcome by Esophageal Dilation

10-20 21-30 31-40 41-50 51-60 61-70 70+0

102030405060708090

100100 100 100 100

94

82 78

0 0 0 06

18 22

SuccessFailure

Figure 3. Outcome by Age