Delta-integrated relaxation pressures as a new high-resolution manometry metric to predict the positive outcome of laparoscopic Heller-Dor in patients with achalasia

• Published in: Journal of gastrointestinal surgery 2025-02, Vol.29 (2), p.101928, Article 101928
• Main Authors: Costantini, Andrea, Pittacolo, Matteo, Nezi, Giulia, Capovilla, Giovanni, Costantini, Mario, Vittori, Arianna, Santangelo, Matteo, Provenzano, Luca, Nicoletti, Loredana, Forattini, Francesca, Moletta, Lucia, Valmasoni, Michele, Savarino, Edoardo V., Salvador, Renato
• Format: Article
• Language: English
• Subjects: Adult; Aged; Esophageal achalasia; Esophageal Achalasia - physiopathology; Esophageal Achalasia - surgery; Esophageal Sphincter, Lower - physiopathology; Esophageal Sphincter, Lower - surgery; Female; Heller Myotomy - methods; High-resolution manometry; Humans; Integrated relaxation pressures; Laparoscopic Heller-Dor; Laparoscopy - methods; Male; Manometry - methods; Middle Aged; Outcome; Predictive Value of Tests; Pressure; Retrospective Studies; ROC Curve; Treatment Outcome
• ISSN: 1091-255X; 1873-4626; 1873-4626
• DOI: 10.1016/j.gassur.2024.101928

There is no consensus on the definition of failure after treatment in patients with achalasia. The Eckardt score is used to define clinical outcomes. However, objective metrics are lacking. This study aimed to identify whether any high-resolution manometry (HRM) parameters may be useful in predicting a positive outcome after laparoscopic Heller-Dor (LHD). Patients who underwent LHD between 2012 and 2022 were enrolled. The patients were divided according to the outcome: the success group (SG) and the failure group (FG). In addition to the common HRM parameters, we measured the difference between pre- and postoperative integrated relaxation pressures (∆-IRPs). A receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of each HRM parameter. Of note, 336 patients (92.3%) were classified in the SG, and 28 patients (7.7%) were classified in the FG. No difference was found in terms of manometric types, symptom duration, and history of previous treatments. Preoperative lower esophageal sphincter (LES) pressure and IRP were higher in the SG than in the FG (41 vs 35 mm Hg [P =.03] and 33 vs 26 mm Hg [P =.002], respectively). The postoperative LES metrics were similar between the 2 groups, except for the ∆-IRP that was higher in the SG (23 mm Hg [IQR, 15–31]) than in the FG (14 mm Hg [IQR, 9–17]) (P =.0002). In the univariate analysis, age, LES preoperative pressure, IRP, and ∆-IRP were factors able to predict a positive clinical outcome. In the multivariate analysis, the ∆-IRP was the only parameter independently related to clinical success (odds ratio, 0.94; 5%–95% CI, 0.89–0.99). The ROC curve for the ∆-IRP showed an area under the curve of 0.71, with a threshold value set at 16.5 mm Hg (sensibility of 71% and specificity of 70%). Our data showed that the ∆-IRP with a threshold of 16.5 mm Hg could represent a new objective tool for predicting the long-term positive outcome of LHD in patients with esophageal achalasia.