The relationship between manometric subtype and outcomes of surgical treatment for patients with achalasia

The Chicago Classification describes three distinct subtypes of achalasia and it appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment for achalasia using an extended Heller myotomy for each subtype and to identify additional parameters that may predict the success of therapy. 72 consecutive patients with achalasia were evaluated at the University of Washington between 2008 and 2013. Symptom duration, patient age, and the degree of esophageal dilation (stage 1-3) as assessed by radiography were determined. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within 1 year. Long-term follow-up data of 25 patients were available in the form of a survey evaluating overall satisfaction with the operation. The distribution of patients according to subtype included 13 with type I, 54 with type II, and 5 with type III. All of the type I patients had some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. All patients underwent uneventful laparoscopic-extended Heller myotomy. Two patients were classified as failures, including one with type I and one with type II achalasia; however, further investigation revealed the cause of both failures to be the development of peptic stricture. Only one of the 25 patients with long-term follow-up reported dissatisfaction with the treatment result and indicated persistent chest pain without dysphagia. Laparoscopic-extended Heller myotomy is a highly successful treatment for patients with achalasia and outcomes do not appear to vary significantly according to the manometric subtype. Failures may result from reflux in patients who develop esophagitis or stricture. Chest pain is not always responsive to esophagogastric myotomy despite relief of dysphagia.