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EXTENDING MYOTOMY BOTH DOWNWARDS AND UPWARDS FOR MANOMETRIC PATTERN III ACHALASIA PATIENTS IMPROVES THE FINAL OUTCOME
Giovanni Capovilla*1, Renato Salvador1, Luca Provenzano1, Guerrino Voltarel1, Anna Perazzolo1, Dario Briscolini1, Loredana Nicoletti1, Andrea Costantini2, Stefano Merigliano1, Mario Costantini1
1Surgery, University of Padova, Padova, Italy; 2School of Medicine, Università Cattolica Sacro Cuore, Rome, Rome, Italy
BACKGROUND: Achalasia is at present classified in 3 manometric patterns following the Chicago Classification v3.0. Pattern III is the most unfrequent pattern and is correlated with the worst outcome after all available treatments. In previous published studies, we have observed that in addition to the spastic area, pattern III achalasia patients had also a longer Lower Esophageal Sphincter than the patients with the other two patterns. In this study, we aimed to investigate the final outcome after classic laparoscopic myotomy (CLM) as compared with a longer laparoscopic myotomy both downwards and upwards (LLM) in patients with manometric pattern III achalasia.
METHODS: The study population consisted of 50 consecutive patients with a definitive diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997-2017. Patients who had already been treated for achalasia were ruled out. Patients before 2010 had a traditional CLM procedure while patients after 2010 had a LLM. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, manometry (conventional or HRM) were performed before surgery. All conventional manometric tracings, before 2010, were reviewed and re-classified according to the manometric-pattern classification, whereas after 2010 the HRM data were prospectively collected. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 8).
RESULTS: Of the 50 patients representing the study population, 23 had CLM and 27 had LLM. In addition, all the patients add an anterior, partial fundoplication (Dor). The patients' demographic and clinical parameters (sex, symptom score, duration of symptoms, esophageal diameter) were similar in both groups. No intraoperative mucosal lesions were detected. The median of follow-up was 61 months (IQR: 35-93) in the CLM and 24 months (IQR: 16-36) in the LLM.
As a whole, the two groups had a different drop in their symptom score: 21 (17-26) versus 6 (0-8), and 21 (18-27) versus 3 (0-6) for the CLM and LLM respectively (p<0.05). Moreover, failures were 7/23 (30%) in the CLM and 3/27 (11.1%) in the LLM (p<0.001). All the patients whose the surgery failed subsequently underwent one or more endoscopic pneumatic dilations with an improvement of the symptom score. Finally, an abnormal acid exposure was detected after the treatment in 4 patients of CLM and in 3 of LLM (p=n.s.).
CONCLUSIONS: In spite of intrinsic limitations of the study (retrospective, different time window of the two procedures and different follow-up), the extension of the length of the myotomy both downwards and upwards improves the final outcome of the laparoscopic Heller-Dor procedure in patients with pattern III achalasia. On the other hand, a longer myotomy does not influence the development of postoperative gastroesophageal reflux.
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