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The Impact of Heller Myotomy on the Integrated Relaxation Pressure in Esophageal Achalasia
Renato Salvador*1, Edoardo V. Savarino1, ELISA Pesenti1, Lorenzo Spadotto1, Tommaso Giuliani1, Francesca Galeazzi1, Loredana Nicoletti1, Giovanni Zaninotto2, Stefano Merigliano1, Mario Costantini1
1Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy; 2Surgery, Imperial College, London, United Kingdom
Background: A new classification for the diagnosis of primary esophageal motility abnormalities by means of High Resolution Manometry (HRM) has been recently proposed and a new parameter, the Integrated Relaxation Pressure (IRP), has been included for the assessment of esophagogastric junction (EGJ) relaxation. Indeed, the diagnosis of achalasia is established by HRM on the basis of an IRP>15mmHg and absence of normal peristalsis in the esophageal body. Our aim was to assess the effect of Heller myotomy on IRP in achalasia patients.
Patients and Methods: We evaluated all consecutive patients who underwent laparoscopic Heller myotomy as first treatment from 2009-2014 and had a HRM evaluation before and after surgery. Patients who had already been treated for achalasia (with Heller myotomy, endoscopic treatment) were excluded from the study. The diagnosis of primary achalasia was established by esophageal manometry on the basis of accepted esophageal motility characteristics (i.e. absence of normal peristalsis in the esophageal body). Symptoms were collected and scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy, HRM were performed, before and 6 months after surgical treatment. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 10).
Results: 139 consecutive achalasia patients (M:F=72:67) represented the study population. All the patients had 100% simultaneous waves but 11 had a IRP<15 mmHg. According to the HRM classification, patients were classified as having: 58 (42.3%) type I, 63 (46%) type II and 16 (11.7%) type III. At a median follow-up of 24 months, the symptom score was significantly lower after surgery (median preoperative score 18 [IQR 11-20] vs median postoperative score 0 [IQR 0-3]; p<0.0001). The resting LES pressure (median preoperatively 27 [IQR 19-36] vs median postoperatively 11 [IQR 8-14]; p<0.001) and IRP (median preoperatively 27.4 [IQR 20.4-35] vs median postoperatively 7.1 [IQR: 4.4-9.8]; p<0.001). The surgical procedure was completed laparoscopically in all the patients. The failures of surgical treatment were 7 (5%). At univariate analysis IRP was correlated with the gender, LES basal and resting pressure, and the dysphagia score.
Conclusion: This is the first study evaluating the role of IRP in achalasia and its modifications after surgery. An increased preoperative IRP directly correlated with dysphagia severity in achalasia patients. Heller myotomy was able to resolve this symptom by reducing the IRP to a value lower than 10 mmHg.
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