Achalasia symptom response after Heller myotomy segregated by high-resolution manometry subtypes

• Published in: Journal of gastroenterology Vol. 51; no. 2; pp. 112 - 118
• Main Authors: Patel, Amit, Patel, Ami, Mirza, Faiz A., Soudagar, Samad, Sayuk, Gregory S., Gyawali, C. Prakash
• Format: Journal Article
• Language: English
• Published: Tokyo Springer Japan 01.02.2016; Springer; Springer Nature B.V
• Subjects: Abdominal Surgery; Achalasia; Colorectal Surgery; Databases, Factual; Deglutition disorders; Deglutition Disorders - etiology; Esophageal Achalasia - complications; Esophageal Achalasia - surgery; Esophageal Sphincter, Lower - surgery; Esophagoscopy; Female; Follow-Up Studies; Gastroenterology; Hepatology; Humans; Kidney Failure, Chronic - etiology; Male; Manometry; Medicine; Medicine & Public Health; Middle Aged; Original Article—Alimentary Tract; Patient Satisfaction; Prognosis; Prospective Studies; Severity of Illness Index; Strategic planning (Business); Surgical Oncology; Treatment Outcome; Heller myotomy; Achalasia; High-resolution manometry
• ISSN: 0944-1174; 1435-5922
• DOI: 10.1007/s00535-015-1088-6

Background Achalasia is classified into three HRM subtypes that predict outcomes from diverse management strategies. We assessed if symptomatic response varied when a single management strategy—Heller myotomy (HM)—is employed. Methods Treatment-naive subjects with achalasia referred for HM were followed in this observational cohort study. Chicago criteria designated achalasia subtypes (subtype I: no esophageal pressurization; subtype II: panesophageal pressurization in ≥20 % swallows; subtype III: premature contractions in ≥20 % swallows). Symptom questionnaires assessed symptom burden before and after HM on five-point Likert scales (0 = no symptoms, 4 = severe symptoms) and on 10-cm visual analog scales (global symptom severity, GSS); satisfaction with HM was recorded similarly. Data were analyzed to determine predictors of GSS change across subtypes. Results Sixty achalasia subjects (56.1 ± 2.4 years, 55 % female) fulfilled inclusion criteria, 15 % with subtype I, 58 % with subtype II, and 27 % with subtype III achalasia. Baseline symptoms included dysphagia (solids: 85 %, liquids: 73 %), regurgitation (84 %), and chest pain (35 %); mean GSS was 7.1 ± 0.3. Upon follow-up 2.1 ± 0.2 years after HM, GSS declined to 1.9 ± 0.4 ( p  < 0.001), with surgical satisfaction score of 8.7 ± 0.3 out of 10; these were similar across achalasia subtypes. On univariate analysis, female gender, Eckardt score, severity of transit symptoms, and maximal IRP predicted linear GSS improvement; female gender ( p  = 0.003) and dysphagia for liquids ( p  = 0.043) remained predictive on multivariate analysis. Conclusions When a uniform surgical approach is utilized, symptomatic outcome and satisfaction with therapy are similar across achalasia subtypes. Female gender and severity of dysphagia for solids may predict better HM outcome.