Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients

Abstract

BackgroundCurrent treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique.MethodsWe enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM.ResultsTwenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months.ConclusionsThe use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.

Present insight on achalasia – from diagnosis to treatment

“…In the future, further prospective studies are needed to establish optimal, tailored-to-patient treatment. Promising findings were revealed in recent study presenting the benefits of the intraoperative HRM in modification of myotomy [68]. Finally, the growing insight into the pathophysiology of achalasia, particularly the immunological aspects, may result in innovative treatment aimed at halting the disease at an early stage [29].…”

“…Overall treatment effectiveness may be improved by choosing the proper therapy for each different patient classified according to subclassification. Existing treatment is only palliative and none of available treatment modalities is able to achieve complete success; therefore, up to 56% of patients may require additional treatment within 5 years [68]. Temporal placement of wide, partially covered self-expandable metal stents (SEMS) appears to be an alternative treatment specially in high-risk surgical patients.…”

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

“…Spastic disorders including distal esophageal spasm and type III (spastic) achalasia benefit from peroral endoscopic myectomy (POEM) surgery while type I or II achalasia have better outcomes with interventions focused on the LES (pneumatic dilation or Heller's myotomy of the LES) (228)(229)(230)(231). HRM can also diagnose hiatal hernias (232) or evaluate esophageal motility before (233) and after anti-reflux fundoplication surgery (234,235).…”

High Resolution Manometry Guidance During Laparoscopic Fundoplication in Pediatric Surgically “Fragile” Patients: Preliminary Report

“…The anatomical relationship and diagnosis of sliding hernia if these components are spatially separated is also feasible [19][20][21]. To date, esophageal intraoperative manometry has usually been used to monitor the high-pressure esophageal zone during achalasia surgery, in both adults and children [22,23].…”