Partial recovery of peristalsis after myotomy for achalasia: more the rule than the exception

Abstract

Importance: Although successful treatment of achalasia depends on alleviating the obstruction at the esophagogastric junction, the postintervention contractile and pressurization pattern may also play a role in outcome.

Objective: To determine whether myotomy that alleviates the esophagogastric junction outflow obstruction in achalasia might improve peristalsis.

Design: Retrospective study from August 1, 2004, through January 30, 2012.

Setting: Two tertiary care hospitals in Chicago and Lyon.

Patients: We included 30 patients (18 male; mean age [range], 43 [17-78] years), of whom 8 had type 1 (26.6%), 17 had type 2 (56.7%), and 5 (16.7%) had type 3 achalasia according to the Chicago classification.

Interventions: Esophageal high-resolution manometry before and after laparoscopic or endoscopic myotomy.

Main outcomes measure: The integrity of peristalsis, characterized as intact, weak contractions; frequent failed peristalsis; or premature contractions.

Results: Although peristaltic fragments were evident only in patients with type 3 achalasia before treatment, intact, weak, or frequent failed peristalsis was encountered in 5 patients with type 1 (63%), 8 with type 2 (47%), and 4 with type 3 (80%) achalasia after myotomy. One patient with type 3 achalasia had distal esophageal spasm after treatment. In patients with a postmyotomy integrated relaxation pressure of less than 15 mm Hg, only 10 (40%) had persistent absent peristalsis. Panesophageal pressurization disappeared after myotomy in 16 of 19 patients. In the 5 patients with postmyotomy integrated relaxation pressure of more than 15 mm Hg, 4 had weak peristalsis and 1 had absent peristalsis.

Conclusions and relevance: Reduction or normalization of the esophagogastric junction relaxation pressure achieved by myotomy in achalasia is associated with partial recovery of peristalsis in some patients, suggesting that the disease process progresses from the esophagogastric junction to the esophageal body. Whether the return of peristalsis is predictive of an improved therapeutic outcome requires further study.

Figure 1

Esophageal pressure topography studies of patients with type 2 (upper panel) and 3 (lower panel) achalasia before (left) and after (right) myotomy. Pressures are recorded along the esophagus from the upper esophageal sphincter (UES) to the esophagogastric junction (EGJ). The x-axis represents time. Pressure amplitudes are coded by color as scaled on the right. The patient illustrated in Panel A had type 2 achalasia characterized by impaired EGJ relaxation (mean IRP 45 mmHg) and pan-esophageal pressurization. After POEM, he had some instances of weak peristalsis characterized by proximal and distal defect in the contraction front. Note that post myotomy EGJ pressure was extremely low. The Panel B patient presented with type 3 achalasia characterized by impaired EGJ relaxation (mean IRP 30.1 mmHg) and premature contractions (distal latency DL <4.5 s). After myotomy the EGJ pressure significantly decreased, but premature contractions persisted (DL< 4.5 s).

Figure 2

Patterns of post-myotomy contractility. Panel A illustrates failed peristalsis in a patient with type 2 achalasia treated with Heller without fundoplication. Panel B illustrates a weak contraction with a large break in the 20 mmHg isobaric contour in a patient with type 2 achalasia treated with Heller with Toupet fundoplication. Note that the contraction had both a proximal and a distal defect. In Panels A and B the pressure at the level of the esophago-gastric junction (EGJ) is very low and no high pressure zone was identified. Panel C illustrates compartmentalized esophageal pressurization in a patient with type 2 achalasia treated with Heller and Dor fundoplication. Post-operatively the mean IRP was 17 mmHg, thereby meeting the criterion for esophagogastric junction outflow obstruction. A weak contraction with a large break in the 20 mmHg isobaric contour was also noted.

Figure 3

Post-treatment motility according to pre-treatment achalasia subtype. Absent peristalsis was the most frequent pattern observed in patients with type 2 achalasia before myotomy whereas weak or frequent failed peristalsis were more frequently observed in type 1 patients. All patients but one with pre-treatment type 3 achalasia had persistent contractile activity after myotomy: type 3A patients exhibited frequent failed peristalsis and distal esophageal spasm while both type 3B patients had post-treatment esophagogastric junction outflow obstruction.

Figure 4

Post-treatment motility according to treatment modality. All patterns of contractile activity were observed with each treatment modality.