Outcomes of Treatment for Achalasia Depend on Manometric Subtype

Wout O. Rohof; Renato Salvador; Vito Annese; Stanislas Bruley Des Varannes; Stanislas Chaussade; Mario Costantini; J. Ignasi Elizalde; Marianne Gaudric; André J. Smout; Jan Tack; Olivier R. Busch; Giovanni Zaninotto; Guy E. Boeckxstaens


Gastroenterology. 2013;144(4):718-725. 

In This Article

Abstract and Introduction


Background & aims: Patients with achalasia are treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM), which have comparable rates of success. We evaluated whether manometric subtype was associated with response to treatment in a large population of patients treated with either PD or LHM (the European achalasia trial).

Methods: Esophageal pretreatment manometry data were collected from 176 patients who participated in the European achalasia trial. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score; treatment was considered successful if the Eckardt score was 3 or less. Manometric tracings were classified according to the 3 Chicago subtypes.

Results: Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84).

Conclusions: A higher percentage of patients with type II achalasia (based on manometric tracings) are treated successfully with PD or LHM than patients with types I and III achalasia. Success rates in type II are high for both treatment groups but significantly higher in the PD group. Patients with type III can probably best be treated by LHM. Trialregister.nl number NTR37; ISRCTN56304564.


Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES) resulting in an impaired bolus transport and stasis of food in the esophagus.[1] Because its exact etiology still is unknown, current treatment options of achalasia are directed only at relieving the functional obstruction at the level of the LES and consist mainly of endoscopic pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM).[2–6]

It generally is accepted that the loss of enteric neurons, in particular nitric oxide–releasing neurons, is responsible for the lack of peristalsis and impaired relaxation of the LES during swallowing.[1,7,8] Recently, 3 manometric subtypes were identified based on the residual esophageal wave pattern: type I, in which the esophageal body shows minimal contractility; type II, in which there is no peristalsis but intermittent periods of compartmentalized esophageal pressurization; and type III, in which there are spastic contractions in the distal esophagus (Figure 1).[9] Importantly, this study suggested that the efficacy of treatment, mainly consisting of PD, strongly varies depending on the manometric type. Success rates were indeed significantly higher for type II achalasia (96%) compared with type I (56%) and type III (29%) achalasia. Also, in patients treated by LHM, differences in treatment success between the subtypes were confirmed, with success rates of 85%, 95%, and 70% for types I, II, and III, respectively.[9–11] However, these studies had a different definition of treatment success and patients were not followed up prospectively, making comparison between PD and LHM impossible.

Figure 1.

Based on the residual wave type on HRM, 3 subtypes of achalasia can be determined. (A) No distal pressurization is observed in type I (AI), whereas panesophageal pressurizations and spastic contractions are observed in type II (AII) and type III (AIII), respectively. (B) A similar classification can be made when conventional manometry is used. Note that pressure recordings in type II achalasia are similar in every line tracing, compatible with panesophageal pressurization.

Recently, the efficacy of PD and LHM was compared prospectively in a large European multicenter trial. More than 200 patients were included, randomized, and followed up for more than 2 years (mean follow-up period, 43 mo). This study showed that LHM was not superior to PD and revealed success rates of 85%–95% for both treatments.[12] Because esophageal manometry was performed in all patients before treatment, this data set ideally is suited to identify the impact of the manometric subtype on clinical outcome in both treatment arms in a prospective manner using the same criteria of treatment success. Therefore, we reviewed the tracings of the European Achalasia Trial to evaluate the following: (1) whether the manometric subtype indeed determines the success rate of treatment, (2) whether the subtype should dictate the choice of treatment, and (3) whether specific symptoms or functional data could explain the differences in success rates.