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The Impact of Heller Myotomy on Integrated Relaxation Pressure in Esophageal Achalasia

  • 2015 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

A new high-resolution manometry (HRM) parameter, the integrated relaxation pressure (IRP), has been proposed for the assessment of esophageal-gastric junction (EGJ) relaxation. Our aim was to assess the effect of Heller myotomy on IRP in achalasia patients.

Methods

We prospectively collected data on achalasia patients who underwent HRM between 2009–2014. Barium swallow was used to assess esophageal diameter and shape. Manometric diagnoses were performed by using the Chicago Classification v3. All patients with a confirmed diagnosis of achalasia were treated surgically with Heller Myotomy

Results

One hundred thirty-nine consecutive achalasia patients (M:F = 72:67) represented the study population. All the patients had 100 % simultaneous waves but 11 had an IRP < 15 mmHg. At median follow-up of 28 months, the median of IRP was significantly lower after surgery (27.4 [IQR 20.4–35] vs 7.1 [IQR 4.4–9.8]; p < 0.001), and so were the lower esophageal sphincter (LES) resting pressure (27 [IQR 18–33] vs 6 [IQR 3–11]; p < 0.001). At univariate analysis, IRP correlated with the gender, LES resting residual pressure, and dysphagia score.

Conclusions

This is the first study to have examined the role of IRP in achalasia, and how it changes after surgical treatment. An increased preoperative IRP correlated directly with a more severe dysphagia. The IRP was restored to normal by Heller myotomy.

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Authors and Affiliations

  1. Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Padova, Italy

    Renato Salvador, Edoardo Savarino, Elisa Pesenti, Lorenzo Spadotto, Giovanni Capovilla, Francesca Galeazzi, Loredana Nicoletti, Stefano Merigliano & Mario Costantini

  2. Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy

    Francesco Cavallin

Authors
  1. Renato Salvador
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  2. Edoardo Savarino
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  3. Elisa Pesenti
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  4. Lorenzo Spadotto
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  5. Giovanni Capovilla
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  6. Francesco Cavallin
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  7. Francesca Galeazzi
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  8. Loredana Nicoletti
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  9. Stefano Merigliano
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  10. Mario Costantini
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Correspondence to Renato Salvador.

Additional information

Primary Discussant

Blair A. Jobe, M.D. (Pittsburgh, PA)

Dr. Salvador presents a thorough analysis of the use of IRP in the assessment of achalasia prior to and following Heller myotomy with Dor fundoplication. There was a direct correlation between the severity of dysphagia and IRP values preoperatively. From these results, it is apparent to me that we can use this value without reservation when evaluating our patients and attempting to make the diagnosis. When compared to nadir pressure, IRP has been shown to be much more sensitive that thus false negatives are reduced.

1) In 11 of your patients, there was a normal IRP preoperatively and all patients had a successful outcome with myotomy. Will you please provide your thoughts as to why this may be and comment on whether or not these patients had delayed clearance on impedance manometry (if your system has this capability)?

2) In the 7 patients that failed surgical intervention, all had normalization of the IRP post myotomy and were subsequently treated with pneumatic dilation with response in all but one. Did more of those patients have type III achalasia or sigmoidization of the esophageal body with “sink trapping?”

3) Why do you think IRP is higher in women?

Closing Discussant

Dr. Salvador

1) We don’t have impedance manometry at our laboratory. The impedance technique could probably help to clarify the diagnosis of this group of patients, but all these 11 patients had a barium swallow that showed a delayed bolus transit and a holdup of the barium at cardia level.

2) Only one of our patients whose surgery failed had a type III achalasia and none of them had a sigmoid esophagus. We are therefore unable to offer a hypothesis to explain the real cause of the treatment’s failure in these patients.

3) It’s hard to say why the female patient had a higher IRP than the male, but our results are consistent with two previous studies. Jung et al. calculated the normal values for the CC and reported that the IRP was significantly higher in females than in males.29 Vega et al. also published a study using conventional manometry on 129 healthy individuals and reported that the LES resting pressure was higher in females than in males. This may be a mere coincidence, but it is something to be taken into account when making a manometric diagnosis, especially in borderline cases.

Presented at the Digestive Disease Week, Washington, May, 2015

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Salvador, R., Savarino, E., Pesenti, E. et al. The Impact of Heller Myotomy on Integrated Relaxation Pressure in Esophageal Achalasia. J Gastrointest Surg 20, 125–131 (2016). https://doi.org/10.1007/s11605-015-3006-x

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