POEM FOR TREATMENT OF ACHALASIA WITH NORMAL ESOPHAGOGASTRIC JUNCTION RELAXATION

Aims Manometric criteria of achalasia are absent peristalsis and incomplete relaxation of the esophagogastric junction (EGJ). We have experienced patients with clinical and radiological features of achalasia with normal integrated relaxation pressure (IRP< 15 mm Hg). The aim of the study was to assess effectiveness of peroral endoscopic myotomy (POEM) for treatment patients who are not fulfilling the Chicago Classification scriteria of achalasia.

Methods 70 patients (37 women, age 21-78 years) with typical symptoms of achalasia were evaluated using high-resolution manometry (HRM), barium esophagogram, upper endoscopy (UE).

Results HRM detected achalasia I type in 25 (35.7%), achalasia II type in 34 (48.6%), achalasia III type in 3 (4.3%), absent contractility in 8 (11.4%) patients. Manometrical characteristics in absent contractility patients included absent peristalsis, low basal EGJ pressure of 9.3 (5.6-12.5) mm Hg and normal IRP of 8.5 (5.2-10.8) mm Hg. Physical examination of patients with absent contractility did not reveal signs of scleroderma, Eckardt score was 9.2 (7-12)). UE showed esophageal dilatation, cardiac region was closed in all 8 patients. A barium esophagogram revealed esophageal dilatation (widest diameter was 8.5 cm) with bird-beak narrowing of the EGJ. Esophageal stasis was 5.1 (3.7-7.3) cm after 5 minutes. These data confirmed achalasia (despite of normal IRP). POEM was performed to these patients. In 6 months after POEM endoscopy showed opened lower esophageal sphincter, barium esophagogram showed free flow of contrast from the esophagus to the stomach in all 8 patients. Eckardt score improved from 8.7 to 1.7.

Conclusions A subgroup of patients with typical features of achalasia but manometrically normal EGJ relaxation exist. It can be different phenotype of achalasia with low LES pressure and normal IRP, especially in cases of advanced disease. These patients can be considered as achalasia and treated us such.