Results

Clinical and demographic characteristics

The group studied contains a total of 74 with presurgical and postsurgical manometric studies and
clinical evaluation scales. The median age was 41.5 years (RNG 17-78), while 44 patients were
females (59.45 %) The median height was 1.61 m (RNG 1.42-1.85), median BMI was 23.05 kg/m2
(RNG 16-41), median presurgical weight was 59.5 kg (RNG 35-92.5), median weight loss 12 kg (RNG
0-60) an mean symptom duration was 13 months (RNG 1-115). The subtypes of achalasia had a
distribution as follows: type 1 n=34 (45.94 %), type 2 n=36 (48.64 %), type 3 n=1 (1.35 %) and not
classifiable n = 3 (4.05 %) (Table 1)

All patients had a barium swallow contrast study, endoscopy, and high- resolution manometry
established the diagnosis of achalasia in all individuals.

Evaluation of symptoms

The presurgical symptomatology was evaluated with the median Gastro-Esophageal Reflux Disease
Impact Score (GERD) 21 (RNG 4-49), Eating Assessment Tool (EAT-10) 32 (RNG 4-40), Eckard score
9 (RNG 3-26), postsurgical median scores were GERD 3 (RNG 0-30) EAT-10 2 (RNG 0-30) Eckard 2
(0-8). Statistical analysis shows a significant difference between the global scores of the scales
used (p = < 0.0001).

The analysis of individual presurgical symptoms thoughts; GERD pyrosis was present in a 39
(52.70%) subjects with median score of 20 (RNG 13-30), individual parameters of Eckard were:
regurgitation in 66 (89.18%) median of 3 = each meal, dysphagia in 70 (94.59%) median of 3 = each
meal, and retrosternal pain in 60 (81.08%) median of 2 = occasional. Postsurgical symptoms
ending monitoring showed; GERD pyrosis was present in a 4 (5.40%) subjects with median score of
15 (RNG 13-18), regurgitation in 12 subjects (16.21%) median of 0 = none, dysphagia in 28
subjects (37.83%) median of 1 = occasional, and retrosternal pain in 21 subjects (28.37%) median
of 0 = none. Statistical analysis of individual symptoms shows differences between the progression
after surgery (p = < 0.0001) (Figure 1 and Table 2)

Figure 2 show Kaplan-Meier curves of progression of symptoms after surgery, according subtypes
of achalasia (Type 1 and Type 2), tracing median of 20 months (RNG 11-24). The Kaplan-Meier
estimates for both groups of patients were not significantly different. This symptoms after follow-
up decrease in the studied time lapse, verified with a Hazard Ratio (HR) for individual symptoms
(Table 3).

Manometric evaluation

Before surgery, the median presurgical integrated relaxation pressure (IRP) was 27.40 mmHg (RNG
0.2-128.7), distal contractile integral (DCI) 1558 mmHg.s.cm (RNG 0-50729), distal latency (DL) 0
seconds (RNG 0-15), and break 4.07 mmHg (RNG 0-18.23). Manometry presurgical studies present
mean pan pressurized 28.22 %, aperistaltic 35.76 %, partial pressurization 32.23 %, spastic 0 % and
peristaltic 3.91 % waves.

Postsurgical the median IRP was 7.35 mmHg (RNG 0-46.1), DCI 95.34 mmHg.s.cm (RNG 0-5028), DL
0 seconds (RNG 0-7.16), and break 3.66 mmHg (RNG 0-20.38). Manometry postsurgical studies
present mean pan pressurized 0.54 %, aperistaltic 54.79 %, partial pressurization 37.08 %, spastic
7.39 % and peristaltic 13.15 % waves.

After performing the Heller myotomy, a significant decrease in the median IRP, DCI was observed
(p = < 0.0001), but DL and break show not significant difference (p = 0.7645 and p = 0.1297
respectively). In addition, the percentage of pattern waves were modified after surgery, and de
predominant was aperistaltic wave (Figure 3,4).
 Variables Median (RNG)
Female n (%) 44 (59)
Mean age (years) 41.5 (17-78)
Mean height (m) 1.61 (1.42-1.85)
Mean BMI (kg/m2) 23.05 (16-41)
Overweight n (%) 21 (28.37)
Obesity n (%) 7 (9.45)
Mean baseline weight (kg) 71.25 (43.5-126)
Mean preoperative weight (kg) 59.5 (35-92.5)
Mean weight loss (kg) 12 (0-60)
Mean symptom duration (months) 13 (1-115)
I: 34 (45.94 %)
II: 36 (48.64 %)
Type of achalasia n (%)
III: 1 (1.35 %)
Not classifiable: 3 (4.05 %)
Esophageal myotomy (cm) 6 (4-7)
Gastric myomoty (cm) 3 (3-7)
Fundoplication Length (cm) 4 (3-6)
Table 1. Clinical and demographic characteristics

ECKARDT PRE
ECKARD <0.0001*
ECKARDT POST

EAT PRE
EAT-10 <0.0001*
EAT POST

GERD PRE
GERD <0.0001*
GERD POST

Figure 1. Score Symptoms Red. Presurgical Blue. Postsurgical

 Postsurgical median 20
Presurgical Median Wilcoxon test
Variables Months Median (RNG)
(RNG) n = 74 (P value)
n = 74
GERD score 21 (4-49) 3 (0-30) < 0.0001
EAT score 32 (4-40 2 (0-30) < 0.0001
Eckardt score 9 (3-26) 2 (0-8) < 0.0001
GERD pyrosis 20 (13-30) 52.7 % 15 (13-18) 5.4 % < 0.0001
Regurgitation 3 (0-3) 89.18 % 0 (0-3) 16.21 % < 0.0001
Dyphagia 3 (0-3) 94.59 % 1 (0-3) 37.83 % < 0.0001
Restroesternal pain 2 (0-3) 81.08 % 0 (0-3) 28.37 % < 0.0001
Table 2. Scales of symptomatic assessment.

A B
GERD Pyrosis Regurgitation

100 100

80 80

Percent
60
Percent

60

40 40

20 20

0 0

0 2 4 6 8 10 12 0 2 4 6 8 10 12
Duration (months) Duration (months)

C D Dyphagia
Restroesternal pain 100

80
100
Percent

60
80
40
Percent

60 20

40 0

0 2 4 6 8 10 12
20 Duration (months)

0
Tipo 1
0 2 4 6 8 10 12
Tipo 2
Duration (months)

Figure 2. Log-rank: GERD pyrosis p = 0.2207 (Figure 2.A), regurgitation p = 0.8433 (Figure 2.B),
retrosternal pain p = 0.7202 (Figure 2.C) and dysphagia p = 0.7319 (Figure 3.D). Red. Type 1
Blue. Type 2.

Log-rank Type 1 Type 2

Variables
(P value) HR (95% CI of ratio) HR (95% CI of ratio)
GERD pyrosis 0.2207 12.18 (0.2229 - 665.7) 0.08209 (0.0015 - 4.485)
Regurgitation 0.8433 1.146 (0.2971 - 4.418) 0.8728 (0.2263 - 3.365)
Dyphagia 0.7202 0.8659 (0.3929 - 1.907) 1.155 (0.5244 - 2.545)
Restroesternal pain 0.7319 0.8717 (0.3974 - 1.912) 1.147 (0.5230 - 2.516)
Table 3. Statistical analysis of survival curves. HR. Hazard Ratio.
A < 0.0001*
4500
3000
< 0.0001*
1500

50 < 0.0001*
40
30
20
10
0
DCI mean SM DCI mean IRP

8
0.1297

0.7645 0.9536
2

0
Break mean SM LD mean SM LD mean

Figure 3. Manometric parameters. A. Distal Contractile Integral (DCI mmHg.s.cm), Integrated

Relaxation Pressure (IRP mmHg) B. Distal latency (DL seconds), and Break (mmHg)

PRE
POST

0.0031*
60
50 0.5165

40 <0.0001*
30
0.0063*
%

15
0.0002*
10

0
Pan pressurized Aperistaltic Partial Spastic Peristaltic
pressurization

Figure 4. Wave type percentage in manometric study. Red. Presurgical. Blue. Postsurgical.