The Preoperative Manometric Pattern Predicts the Outcome of Surgical Treatment for Esophageal Achalasia
Renato Salvador*, Mario Costantini, Giovanni Zaninotto, Tiziana Morbin, Christian Rizzetto, Lisa Zanatta, Martina Ceolin, Elena Finotti, Emanuela Guirroli, Loredana Nicoletti, Francesco Cavallin, Gianfranco Da Dalt, Ermanno Ancona
Department of Surgical and Gastroenterological Sciences, Clinica Chirurgica I, University of Padua, Padua, Italy
Background: A new manometric classification of esophageal achalasia has been recently proposed, with a suggested correlation with the final outcome of treatment. The aim of this study was to investigate this hypothesis in a large group of patients undergoing laparoscopic Heller myotomy for esophageal achalasia.Patients and Methods: We evaluated the patients who underwent surgery as first treatment from 2001 to May 2009. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, and esophageal manometry were performed, before and 6 months after surgical treatment. All manometric tracings were reviewed and re-classified according to Pandolfino et al (Gastroenterology 2008;135:1526). Patients were divided in three groups according to their manometric patterns: 1) no distal esophageal pressurization (wave amplitude < 30 mmHg): 80 pts; 2) rapidly propagated compartmentalized pressurization (panesophageal pressurization > 30mmHg): 126 pts; 3) rapidly propagated pressurization attributable to spastic contraction: 23 pts. Treatment failure was defined as a postoperative symptom score > 10th percentile of the preoperative score (i.e. > 10).Results: 229 consecutive achalasia patients (M:F=124:105) represented the study population. Demographic and clinical parameters (age, sex, symptom score, duration of symptoms, LES resting and residual pressure) were similar among the three groups. Median follow-up was 31 months (IRQ 14-56). The failures of surgical treatment were significantly different in the three groups (p=0.001, Fisher’s test): group 1 (9/80, 11.3%), group 2 (4/126, 3.2%) and group 3 (6/23, 26.6%). At univariate analysis, manometric pattern (p=0.001), a resting LES pressure > 30 mmHg (p=0.001) and a low chest pain score (p=0.002) were the only factors predictive of a positive final results. At multivariate analysis, these three factors were independently associated to good outcome.Conclusion: This is the first study from a surgical group that assessed the surgical outcome of the 3 manometric achalasia subtypes: patients with panesophageal pressurization and no distal esophageal pressurization have a better outcome after laparoscopic Heller-Dor myotomy.
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