6533b7d0fe1ef96bd125b5cd

RESEARCH PRODUCT

Intraoperative High Resolution Manometry for tailored Heller myotomy in esophageal achalasia: could it give better results?

subject

description

Introduction. Esophageal achalasia is a rare primary motility disorder characterized by impaired lower esophageal sphincter relaxation and absence of esophageal body peristalsis. Achalasia is classified by the Chicago Classification in type I, type II and type III. The present study evaluates how the use of intraoperative high resolution esophageal manometry (IHREM), driving the exact extension of myotomy throughout the esophagus, could improve outcome in achalasic patients, expecially in type III achalasia. Materials and Methods: 49 achalasic patients underwent laparoscopic Heller myotomy and Dor fundoplication: 25 patients (Group 1: 16 type II achalsia, 7 type III achalasia and 2 type I achalasia), were treated with use of intraoperative real-time High Resolution Manometry (IHREM); the 24 patients of group 2 (15 type II achalasia, 5 type III achalasia and 4 type I achalasia) were treated without IHREM. In both groups intraoperative endoscopy was performed.  We compared groups 1 and 2 for operative time and postoperative Eckardt score at 1, 3, 6 and 12 months after surgery. At 12 months control HREM was performed to compare LES resting pressure and IRP (integrated relaxing pressure). Results: Data shows how in group 1 mean LES resting pressure at right after myotomy was 11.8 mmHg. In group 1 Eckardt score decreased from a median preoperative value of 8 to a median postoperative value of 1 at 12 monthts control. On the contrary, in group 2 a drop from 8 to 3 was observed, with  occasional dysphagia as main residual symptom. After 12 months LES resting pressure and IRP values at the control manometry were significantly reduced in group 1 compared to group 2: mean resting pressure of group 1 was 16.25 against a value of 22.25 for group 2 (p<0,001); average IRP for group 1 was 9.44 against a value of 14.73  for group 2 (p<0,001). Conclusion: According to our results IHREM can give a great contribution in treatment of achalasia both detecting residual LES high pressure zone during myotomy, due to not dissected muscle fibers, and driving esophageal myotomy length. These are preliminary data: a greater sample is needed to confirm these encouraging results;  long term follow up is needed.