Role of esophageal manometry in decision making in patients with early cardiac achalasia

Background
Achalasia is an incurable primary motor disorder of the esophagus. Its characteristic manometric features are esophageal body aperistalsis and insufficient relaxation of a frequently hypertensive lower esophageal sphincter in response to swallowing. As the pathogenesis of achalasia is not well understood, the treatment is palliative, aiming at relieving the obstruction at the gastroesophageal junction.
Aim
The aim of this study was to detect the role of preoperative manometry in the choice of the optimal method in the treatment of the early achalasia to be either Heller’s cardiomyotomy (with or without antireflux procedures) or endoscopic balloon dilatation.
Patients and methods
This cohort observational study included 30 patients presented with cardiac achalasia to Ain Shams University hospitals. Patients were assessed with preoperative manometry to determine a proper solution, which was done with a follow-up of at least 6 months starting from October 2018 till October 2020.
Results
All patients were assessed through high-resolution manometry, and symptomatic assessment was done through the Demeester grading score. Both laparoscopic heller myotomy (LHM) and pneumatic dilatation (PD) showed complete success in 82 and 62%, respectively, whereas partial success in 12 and 15%, respectively. Failure was recorded in 6% of LHM and 23% of PD patients.
Conclusion
High resolution manometry proved to be a reliable modality in choosing the optimal method in the treatment of early achalasia based on the following conclusions of our results: LHM is a favorable decision for patients with type I [young age, high Demeester score (>7), and severe elevation in lower esophageal sphincter (LES) pressure ≥35 mmHg], type II, and type III, whereas PD was fit for patients with type I achalasia (old age, low Demeester score, and elevation in LES pressure <35 mmHg).