Page 9 - Read Online

Page 2 of 6 Patti et al. Mini-invasive Surg 2022;6:38 https://dx.doi.org/10.20517/2574-1225.2022.19

Three therapeutic modalities are available today for patients with achalasia: pneumatic dilation (PD),
laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM). The best results are
obtained in centers where an experienced multidisciplinary group composed of radiologists,
gastroenterologists, and surgeons is present, as we believe that treatment should be tailored based on
patients’ characteristics and providers’ experience.

A systematic work-up with a barium swallow, upper endoscopy, and esophageal manometry is necessary
before deciding treatment. In recent years, high-resolution manometry has replaced the old fashion
manometry with water perfused catheters and has evolved into a test which allows defining the type of
achalasia, tailoring therapy, and predicting the outcome of treatment . The Chicago Classification (now in
[1]
its 4.0 version) divides achalasia into three types:

Type I: abnormal median integrated relaxation pressure (IRP) and 100% failed peristalsis;

Type II: abnormal median IRP, 100% failed peristalsis, and 20% of swallows with pan esophageal
pressurization;

Type III: abnormal median IRP and 20% of swallows with premature/spastic contraction and no evidence
of peristalsis (“spastic achalasia”).

A recent study has shown that this classification might describe different stages in the evolution of the
[2]
disease, with type III being the earliest stage, type II an intermediate stage, and type I the final stage . In
addition, it has been suggested that the Chicago Classification might have a prognostic value, with patients
with type II achalasia having better outcomes after endoscopic or surgical treatment than those with type I
or III (type III with the highest failure rates) [3,4,5] .

ACHALASIA TREATMENT
For many decades, pneumatic dilation was the treatment of choice for achalasia, relegating a Heller
[6]
myotomy to the treatment of failures or complications such as perforation . The beginning of the nineties
saw the development of minimally invasive surgery, with the first thoracoscopic Heller myotomy (THM) in
the United States performed by the team at the University of California San Francisco (UCSF) in 1991 .
[7]
The evaluation of the initial 17 patients showed that the operation was feasible, associated with a fast
recovery and return to daily activities, and provided results resembling those of open surgery . However, it
[7]
soon became clear that the lack of fundoplication caused pathologic reflux in a large number of patients.
This finding prompted a switch to a LHM with the addition of a partial fundoplication. A comparison of 30
THM and 30 LHM by the UCSF team confirmed that the fundoplication made a significant difference as
the incidence of pathologic reflux (as measured by pH monitoring) was 60% after THM, but only 10% after
LHM with a 180° anterior Dor fundoplication . The importance of fundoplication in addition to the
[8]
myotomy was confirmed later by Richards and others in a prospective and randomized trial comparing an
LHM alone and an LHM with Dor fundoplication . As measured by pH monitoring, pathologic reflux was
[9]
present in 47% of patients after LHM but only 9% after LHM and Dor fundoplication. A recent meta-
analysis by Schlottmann et al. has confirmed that the incidence of pathologic reflux (by pH monitoring)
after LHM and partial fundoplication was 11% .
[10]

LHM was adopted for more than a decade in many centers as the primary form of treatment for esophageal
achalasia due to its high success rate. However, some centers continued to use PD as the initial therapeutic
approach (using LHM for the failures of treatment), as it was very effective in experienced hands. For