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EVALUATION OF ESOPHAGOGASTRIC JUNCTION CONTRACTILITY AFTER DIFFERENT TREATMENTS FOR ACHALASIA
Salvatore Tolone*1, Edoardo V. Savarino2, Nicola de Bortoli3, Marzio Frazzoni4, Manuele Furnari5, Leonardo Frazzoni6, Mariachiara Lanza Volpe1, Vincenzo Savarino5, Ludovico Docimo1, Lee L. Swanstrom7
1Second University of Naples, Naples, Italy; 2University of Padua, Padua, Italy; 3University of Pisa, Pisa, Italy; 4Baggiovara Hospital, Modena, Italy; 5University of Genoa, Genoa, Italy; 6University of Bologna, Bologna, Italy; 7University of Chicago, Chicago, MI
Background The management of achalasia targets relieving the obstruction at the esophagogastric junction (EGJ) by pneumatic dilation (PD), laparoscopic Heller myotomy (LHM) plus a fundoplication variant (Dor, Toupet and more rarely Nissen/Nissen-Rossetti). However, effective ablation of the LES barrier can induce gastroesophageal reflux disease (GERD). Recently, new metrics to evaluate EGJ function with high resolution manometry (HRM) have been introduced, such as EGJ contractile integral (EGJ-CI). Currently there are few data investigating how achalasia treatments impact EGJ function based on these metrics. We aimed to assess the EGJ-CI metric in achalasia before and after different treatments, to verify if post-operative changes in this metric correlate to symptom relief and iatrogenic GERD following surgical treatments.
Methods Between 2014 and 2015, we enrolled consecutive achalasia patients. All patients underwent clinical evaluation with Eckardt and GERDQ score, as well as upper endoscopy, barium esophagogram and HRM before and 6 months after treatment. Achalasia was classified according to the Chicago Classification V3.0. The EGJ-CI was calculated using the distal contractile integral tool-box during three consecutive respiratory cycles. Patients underwent to pneumatic dilatation (PD), or LHM plus a Dor (LHM-D), Toupet (LHM-T) or a Nissen-Rossetti (LHM-NR) fundoplication. Ethical approval for the study was obtained.
Results We enrolled 35 achalasia patients (14 Type I, 16 Type II and 5 Type III). Ten patients underwent PD, 11 LHM-D, 8 LHM-T and 6 LHM-NR. At baseline, no differences among treatment groups regarding age, sex, pre-operative mean Eckardt score, GERDQ score, integral relaxation pressure (IRP) and EGJ-CI were recorded. All Type III subjects underwent LHM-D (3) and LHM-T (2). After all the procedures, in all the patients there was a significant decrease in Eckardt score, IRP and EGJ-CI (p<0.001, <0.001 and <0.05, respectively). PD and LHM-NR showed higher EGJ-CI (20±9.3 and 25.3±11.1 mmHg*cm, respectively) and IRP (12.2±3.4 and 13±4.5, respectively) than LHM-D and LHM-T (18.4±5.9, p<0.05 and 9.3±4.1 p<0.05 mmHg*cm, respectively for EGJ-CI; 5.2±2.5, p<0.05 and 2.3±3.7 p<0.001 mmHg*cm, respectively for IRP). Post-operative Eckardt score was lower in LHM-D and LHM-T (2.1±0.5 and 2.0±0.6, respectively) than PD and LHM-NR (4.2±1.0, p<0.01 and 3.7±1.5, p<0.05). Post-operative GERDQ score was significant higher in LHM-T (3.0±1.7 vs. 8.2±3.9, p<0.05). Low post-operative EGJ-CI values correlated with an increased risk of higher post-operative GERDQ score (p<0.05, odds ratio 4.223, 95% CI 0.964 - 2.123).
Conclusions All procedures performed to treat achalasia produced an adequate relief of dysphagia. LHM-D and LHM-T seem to result in a stronger alteration of the EGJ, with LHM-T resulting in an increased risk of post-operative reflux.
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