Laparoscopic Heller Myotomy for Type II Achalasia

Oscar M. Crespin, MD; Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD

Disclosures

March 26, 2013

New Achalasia Classification by HRM

Pandolfino and colleagues[1] described 3 distinct manometric patterns of esophageal body contractility in achalasia:

  • Type I -- classic achalasia: no distal esophageal pressurization (< 30 mm Hg) in at least 8 of 10 swallows;

  • Type II -- achalasia with compression: at least 2 test swallows associated with panesophageal pressurization > 30 mm Hg; and

  • Type III -- spastic achalasia: 2 or more spastic contractions, with or without periods of compartmentalized pressurization.

Although all 3 subtypes involve impaired gastroesophageal junction (GEJ) relaxation and aperistalsis, they each represent distinct pathophysiologic scenarios and possibly an explanation for some of the observed variability in treatment response.

Pandolfino and colleagues[1] analyzed 83 patients with achalasia (16 with type I, 46 with type II, and 21 with type III) for whom follow-up was sufficient to assess treatment response. Patients with type I disease underwent an average of 1.6 therapeutic interventions over a mean follow-up of 19 months and experienced a response rate of 56% after their most recent therapy. Ten of 16 patients responded to pneumatic dilation; in the remaining 6, endoscopic management failed, and they went on to Heller myotomy.

Patients with type II achalasia underwent an average of 1.2 interventions during a mean follow-up of 20 months and had a response rate of 96%. Six of 46 patients responded to botulinum toxin, 25 responded to pneumatic dilation, and the remaining 15 responded to Heller myotomy as the last intervention.

Patients with type III disease underwent an average of 2.4 interventions during a mean follow-up of 20 months and had a response rate of 29%. Eight of 21 patients responded to botulinum toxin, 8 responded to pneumatic dilation, and 5 responded to Heller myotomy as the last intervention.

Salvador and colleagues[2] evaluated 246 patients with achalasia who underwent Heller myotomy as their initial treatment. According to the new manometric classification, 96 patients were classified as having type I achalasia, 127 as having type II, and 23 as having type III. Patients with type I disease had a failure rate of 14.6% (14 of 96); those with type II achalasia had the lowest incidence of failure, at 4.7% (6 of 127); and those with type III had a failure rate of 30.4% (7 of 23).

Figure 4. Manometric pattern for the next question, below.

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