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

Abstract

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.

Achalasia: new perspectives on an old disease

“…Residual symptoms are reportedly highest with type 3, where HM is favored over PD. The common theme across all three subtypes is adequate LES disruption; indeed, use of a uniform surgical approach with HM demonstrated no differences in outcome across the three subtypes . Nevertheless, PD remains an easy and clinically useful approach to achalasia management, best utilized in older patients, females and particularly subtype 2 .…”

Impact of symptom burden and health‐related quality of life (HRQOL) on esophageal motor diagnoses

“…In this study, we identified dominant symptoms using questionnaire designation. Similarly, global esophageal symptoms over the previous two weeks were characterized on VAS using GSS 14, 17 . The dominant symptom identification and GSS allowed assessment of both dominant and global symptoms, and facilitated follow-up of esophageal symptoms over time in our study cohort.…”

High‐resolution manometric subtypes as a predictive factor for the treatment of achalasia: A meta‐analysis and systematic review

“…Thus, physicians have sought to identify prognostic factors that can be used to select the most appropriate therapy for specific individuals. Thus far, elder age, male sex and postoperative LES >10 mmHg have been reported to be related to a favorable prognosis . Since the application of HRM and the Chicago classification, different manometric subtypes have also been proposed to serve as potential prognostic factors.…”

“…reported that elder age was the only independent factor that was associated with the success rate of PBD (85.7% in patients <40 years vs 38.5% in those >40 years). Some studies have demonstrated that HRM subtypes of achalasia may be important predictors of patient's clinical outcomes . However, it remains controversial whether symptomatic outcomes after treatment are similar across achalasia subtypes.…”

“…Some studies have demonstrated that HRM subtypes of achalasia may be important predictors of patient's clinical outcomes. [10][11][12] However, it remains controversial whether symptomatic outcomes after treatment are similar across achalasia subtypes. Therefore, we performed a meta-analysis to compare the success rates among manometric subtypes after PBD or LHM, and to assess the potential of manometric subtypes to serve as the prognostic factors for the treatment of achalasia.…”