Brief guidelines for beginners on how to perform and analyze esophageal high-resolution manometry

High-resolution manometry (HRM) is a diagnostic tool for surgeons, gastroenterologists and other healthcare professionals to evaluate esophageal physiology. The Chicago Classification (CC) system is based on a consensus of worldwide experts to minimize ambiguity in HRM data acquisition and diagnosis of esophageal motility disorders. The most updated version, CCv4.0, was published in 2021; however, it does not provide step-by-step guidelines (i.e., for beginners) on how to assess the most important HRM metrics. This paper aims to summarize the basic guidelines for conducting a high-quality HRM study including data acquisition and interpretation, based on CCv4.0, using Manoview ESO analysis software, version 3.3 (Medtronic, Minneapolis, MN).

The evolution of the treatment of esophageal achalasia. Chronicle of a 35-year journey

Over the last few decades, significant improvement has been made in both the evaluation and treatment of esophageal achalasia. The Chicago classification, today in version 4.0, is now the standard for diagnosis of achalasia, providing a classification into 3 subtypes with important therapeutic and prognostic implications. Therapy, which was at first mostly limited to pneumatic dilatation, today includes minimally invasive surgery and peroral endoscopic myotomy, allowing for a more tailored approach to patients and better treatment of recurrent symptoms. This review chronicles my personal experience with achalasia over the last 35 years, describing the progress made in the treatment of patients with achalasia.

Clinical and manometric results of peroral endoscopic myotomy in patients with achalasia: experience in a latin american reference center

INTRODUCTION

Currently there is little information in Latin America on the clinical outcome and manometric evolution of patients with Achalasia undergoing peroral endoscopic myotomy (POEM).

PRIMARY OUTCOME

Evaluate the manometric and clinical changes in adult patients with achalasia after peroral endoscopic myotomy at a referral center in Bogotá, Colombia.

METHODS

Observational, analytical, longitudinal study. Adult patients with achalasia according to the Chicago 4.0 criteria were included. Sociodemographic, clinical and manometric variables were described. To compare the pre- and post-surgical variables, the Student's or Wilcoxon's t test was used for the quantitative variables according to their normality, and McNemar's chi-square for the qualitative variables.

RESULTS

29 patients were included, 55.17% (n=16) women, with a mean age at the time of surgery of 48.2 years (±11.33). The mean post-procedure evaluation time was 1.88±0.81 years. After the procedure, there was a significant decrease in the proportion of patients with weight loss (37.93% vs 21.43% p 0.0063), chest pain (48.28% vs 21.43, p 0.0225) and the median Eckardt score (8 (IQR 8 -9) vs 2(IQR 1-2), p <0.0001). In addition, in fourteen patients with post-surgical manometry, significant differences were found between IRP values (23.05±14.83mmHg vs 7.69±6.06mmHg, p 0.026) and in the mean lower esophageal sphincter tone (9.63±7.2mmHg vs 28.8±18.60mmHg, p 0.0238).

CONCLUSION

Peroral endoscopic myotomy has a positive impact on the improvement of symptoms and of some manometric variables (IRP and LES tone) in patients with achalasia.

Clinical utility of the solid meal test during high-resolution esophageal manometry. A study in a Latin American population

INTRODUCTION AND AIMS

The solid test meal (STM) is a challenge test that is done during esophageal manometry and appears to increase the diagnostic yield of the study. The aim of our analysis was to establish the normal values for STM and evaluate its clinical utility in a group of Latin American patients with esophageal disorders versus healthy controls.

MATERIAL AND METHODS

A cross-sectional study was conducted on a group of healthy controls and consecutive patients that underwent high-resolution esophageal manometry, in which STM was done at the final part of the study and consisted of asking the subjects to eat 200 g of precooked rice. The results were compared during the conventional protocol and the STM.

RESULTS

Twenty-five controls and 93 patients were evaluated. The majority of the controls (92%) completed the test in under 8 min. The STM changed the manometric diagnosis in 38% of the cases. The STM diagnosed 21% more major motor disorders than the conventional protocol; it doubled the cases of esophageal spasm and quadrupled the cases of jackhammer esophagus, whereas it demonstrated normal esophageal peristalsis in 43% of the cases with a previous diagnosis of ineffective esophageal motility.

CONCLUSIONS

Our study confirms the fact that complementary STM during esophageal manometry adds information and enables a more physiologic assessment of esophageal motor function to be made, compared with liquid swallows, in patients with esophageal motor disorders.

Major adverse events related to endoscopic or laparoscopic procedures in achalasia. A systematic review and meta-analysis

INTRODUCTION AND AIMS

Surgical or endoscopic treatments play an essential role in the management of achalasia. The probability of adverse events in the performance of said treatments is a relevant aspect, when establishing the risk-benefit balance. The present study aimed to establish the association between serious adverse events and the performance of those procedures, in adult patients with achalasia.

MATERIALS AND METHODS

A systemic search of randomized and nonrandomized clinical trials, retrospective cohorts, and cases series on adult patients with achalasia that underwent laparoscopic Heller myotomy (LHM), peroral endoscopic myotomy (POEM), or endoscopic balloon dilation, that reported serious adverse events, was carried out on the Medline, CENTRAL, and EBSCO databases. Serious adverse events were defined as: death at 30 days, Clavien-Dindo grade III or higher classification, esophageal or gastric perforation, pneumothorax, mucosal tear, leakage, emphysema, pneumonia, and chest pain. The methodology included the PRISMA guidelines for reporting systematic reviews.

RESULTS

Thirty-five studies were found that reported information on 1,276 patients that underwent POEM, 5,492 that underwent LHM, and 10,346 that underwent endoscopic balloon dilation. The proportions of adverse events for the three techniques were 3.6, 4.9, and 3.1%, respectively.

DISCUSSION AND CONCLUSIONS

The 3 therapeutic interventions evaluated had similar proportions of adverse events. There were few reports of death at 30 days as an outcome and the lack of standardization in reporting adverse events in the studies analyzed was prominent.

Robotic surgery for the treatment of achalasia

OBJECTIVE

To describe the experience of the robotic approach for achalasia surgery in a tertiary center.

MATERIAL AND METHODS

Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed.

RESULTS

45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211 min. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered.

CONCLUSIONS

In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Robotic surgery for the treatment of achalasia

OBJECTIVE

To describe the experience of the robotic approach for achalasia surgery in a tertiary center.

MATERIAL AND METHODS

Patients with achalasia who underwent robotic surgery between May 2010 and April 2019 were analyzed. The study variables were collected in a prospective database and a descriptive analysis was performed.

RESULTS

45 patients (55.6% male) with a mean age of 44 years were included. The main symptom at diagnosis was dysphagia. 19 patients (42.2%) received endoscopic treatment prior to surgery, mostly pneumatic dilation (84.2%). Heller's myotomy associated with Toupet fundoplication was the surgical technique of choice, with a mean operative time of 211minutes. The average stay was 5 days. There were 2 postoperative perforations (4.4%). Perioperative mortality was 0%. The mean follow-up was 64 months. At 3 and 5 years, a significant decrease in the Eckardt score was observed and the manometric study showed a decrease in the lower esophageal sphincter pressure at rest of 58% and 70%, respectively, with persistence of hypomotility of the esophageal body. Pathological gastroesophageal reflux was diagnosed in two patients (5.4%) and 4 (10.8%) presented recurrence of symptoms, requiring endoscopic pneumatic dilations. In 2 cases, the dilations were not effective, so an endoscopic myotomy was considered.

CONCLUSIONS

In our experience, robotic surgery is a safe and effective procedure for the treatment of achalasia.

Gastroesophageal reflux disease after peroral endoscopic myotomy: Short-term, medium-term, and long-term results

INTRODUCTION AND AIMS

Achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and esophageal aperistalsis. The efficacy of peroral endoscopic myotomy (POEM) is similar to that of the Heller myotomy, with an apparently greater prevalence of gastroesophageal reflux disease. Our aim was to determine the presence of GERD in a post-POEM cohort of Mexican patients with achalasia and follow-up of at least 12 months.

MATERIALS AND METHODS

A retrospective cohort study was conducted on post-POEM patients with a minimum of 12 months of follow-up, within the time frame of 2012 to 2017. Pregnant patients were excluded. Serial endoscopy, pH study, and GERDQ application were performed. Univariate and bivariate data analyses were carried out and statistical significance was set at a P<0.05.

RESULTS

Sixty-eight patients had post-POEM follow-up for 12 months. Of those patients, follow-up continued to 24 months for 58, 36 months for 47, 48 months for 39, and 60 months for 25. Mean patient age was 47.8±14.3 years, 57.3% of the patients were women, 77.9% were treatment-naïve, and 54.4% had type II achalasia. The pH study, endoscopy, and questionnaire were positive in 73, 28, and 18% at 3 months; 48, 35, and 13% at 6 months, and 55, 30, and 15% at 12 months, respectively. Once the proton pump inhibitor was begun, the percentages decreased to 5, 2, and 6% at 24 months; 6, 2, and 8% at 36 months; 4,1, and 6% at 48 months; and 3, 1, and 4% at 60 months, respectively. There was no relation between the efficacy of POEM and the presence or intensity of GERD. There were no secondary complications due to gastroesophageal reflux.

CONCLUSIONS

The post-POEM prevalence of GERD was 50% in the short term (12 months), with no evidence of complications at the medium term or long term (60 months). Gastroesophageal reflux was adequately controlled through proton pump inhibitors administration in over 95% of the cases.

Functional and motor gastrointestinal disorders

This article discusses the most interesting presentations at Digestive Disease Week, held in San Diego, in the field of functional and motor gastrointestinal disorders. One of the most important contributions was undoubtedly the presentation of the new Rome IV diagnostic criteria for functional gastrointestinal disorders. We therefore devote some space in this article to explaining these new criteria in the most common functional disorders. In fact, there has already been discussion of data comparing Rome IV and Rome III criteria in the diagnosis of irritable bowel syndrome, confirming that the new criteria are somewhat more restrictive. From the physiopathological point of view, several studies have shown that the aggregation of physiopathological alterations increases symptom severity in distinct functional disorders. From the therapeutic point of view, more data were presented on the efficacy of acotiamide and its mechanisms of action in functional dyspepsia, the safety and efficacy of domperidone in patients with gastroparesis, and the efficacy of linaclotide both in irritable bowel syndrome and constipation. In irritable bowel syndrome, more data have come to light on the favourable results of a low FODMAP diet, with emphasis on its role in modifying the microbiota. Finally, long-term efficacy data were presented on the distinct treatment options in achalasia.

Peroral endoscopic myotomy for the treatment of achalasia and other esophageal motor disorders: Short-term and medium-term results at a Mexican tertiary care center

INTRODUCTION AND AIMS

Achalasia is characterized by the absence of lower esophageal sphincter relaxation and esophageal aperistalsis. Diagnosis is confirmed through high-resolution esophageal manometry. Laparoscopic myotomy is the standard treatment, but peroral endoscopic myotomy (POEM) is a safe and effective alternative, with good short-term and medium-term results. Our aim was to describe the short-term and medium-term experience with POEM at a tertiary care center.

MATERIALS AND METHODS

The study was conducted within the time frame of November 2014 and February 2017. Treatment-naïve achalasia patients and previously-treated achalasia patients that were candidates for POEM were included. A protocolized 24-month follow-up was carried out.

RESULTS

Fifty procedures were included and 31 (68%) were performed on women. Forty-one (82%) of the procedures were carried out on previously untreated patients, 7 (14%) were performed on previously treated patients, and 2 (4%) of the patients had redo-POEM. The mean age of the patients was 48.8±14.1 years. The pre-POEM Eckardt score was 9 and the integrated relaxation pressure was 24.4mmHg. Sixty-eight percent of the patients had type ii achalasia. Procedure time was 80min and myotomy length was 12.6cm. Hospital stay was 3 days and subcutaneous emphysema was the most common adverse event (30%). A total of 22/50 (44%) patients reached the 24-month follow-up, maintaining the Eckardt score and the decrease in the integrated relaxation pressure. There were no deaths. A total of 47.5% of the patients had a positive pH-study at 6 months, 15% had clinical reflux, and 35% presented with mild esophagitis. All the patients were adequately controlled with proton pump inhibitors.

CONCLUSION

POEM is safe and effective in the short term and medium term for the treatment of achalasia and other esophageal motor disorders in Mexican patients.

Laparoscopic graduated cardiomyotomy with anterior fundoplication as treatment for achalasia: experience of 48 cases

INTRODUCTION AND AIMS

At the Upper Gastrointestinal Tract Clinic of the Hospital General de Mexico, achalasia treatment has been standarized through strictly graduated cardiomyotomy. This procedure guarantees a complete myotomy for the satisfactory resolution of dysphagia, a characteristic symptom of achalasia. To ensure the inclusion of the entire lower esophageal sphincter, an 8cm Penrose drain is placed at the surgical site 6cm above the gastroesophageal junction and 2cm in a caudal direction, for accurate laparoscopic measuring. The aim of our study was to evaluate the results of this technique.

MATERIALS AND METHODS

A descriptive, retrospective, longitudinal, and observational study was conducted on a cohort of patients diagnosed with achalasia at the Upper Gastrointestinal Tract Clinic of the Hospital General de México "Dr. Eduardo Liceaga".

RESULTS

The study included 48 patients, 40 of whom had no prior surgical treatment and 8 that presented with recurrence. Forty-seven patients (97.9%) underwent a laparoscopic procedure and conversion to open surgery was required in 2 of them (4.25% conversion rate). Postoperative progression was satisfactory in all cases, with mean oral diet commencement at 52h and mean hospital stay of 5.7 days. No recurrence was registered during the mean follow-up period of 35.75 months and there were no deaths.

CONCLUSIONS

Laparoscopic graduated (strictly measured) cardiomyotomy with anterior fundoplication is a reproducible, efficacious, and safe option for the surgical treatment of achalasia.

In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans

INTRODUCTION AND OBJECTIVES

Achalasia is the most widely studied esophageal motility disorder. No treatment has achieved completely satisfactory results. The laparoscopic Heller esophagomyotomy is currently the most accepted technique. With the advent of minimally invasive surgery, the appearance of peroral endoscopic myotomy (POEM) has promising results. The primary aim of our study was to perform peroral endoscopic esophagomyotomy in animal experimentation models to perfect the technique and later apply it to humans. The secondary aims were to evaluate the intraoperative and postoperative complications and to describe the anatomopathologic findings.

MATERIALS AND METHODS

An experimental study was conducted on 8 live porcine models that were followed for 30 days to identify postoperative complications. Necropsy was then performed to evaluate the histopathologic findings. The international requirements and regulations for animal experimentation were met.

RESULTS

The technique was carried out in all the models. There was one intraoperative death. Pneumothorax was observed in 50% of the units in experimentation and subcutaneous cervical emphysema in 75%, with no significant clinical repercussions. Histologic muscle layer (myotomy) involvement was above the gastroesophageal junction in 87% of the cases and below it in 25%.

CONCLUSION

Peroral endoscopic esophagomyotomy is a feasible, albeit complex, procedure that requires advanced training, and thus should be performed in highly specialized centers. Specific skills in advanced therapeutic endoscopic procedures of this type must continue to be developed through continuing education (ideally in in vivo models), to then be performed on humans.

Difference of achalasia subtypes based on clinical symptoms, radiographic findings, and stasis scores

INTRODUCTION

Three subtypes of achalasia have been defined through high-resolution esophageal manometry: subtype i shows no pressurization with swallows, subtype ii has increased isobaric panesophageal pressure, and subtype iii has distal esophageal spastic non-isobaric contractions. Studies describing the subtypes based on radiographic findings, clinical symptoms, and stasis scores are limited.

AIM

To determine the differences in clinical symptoms, radiographic findings, and stasis scores for the 3 achalasia subtypes.

METHODS

Patients undergoing high-resolution esophageal manometry received a questionnaire about current symptoms and previous treatments. The questions included the presence of symptoms and their severity. Barium swallow tests were performed before the high-resolution esophageal manometry study to evaluate the maximum esophageal diameter. Stasis scores were calculated using the transit patterns on high-resolution esophageal manometry.

RESULTS

One hundred and eight patients with high-resolution esophageal manometry diagnosis of achalasia (n=8, subtype i; n=84, subtype ii; n=16, subtype iii) within the time frame of 1/2012-6/2015 were included in the study. Sex distribution was similar between the subtypes. Patient age was younger for subtype i (38±16 years), compared with subtypes ii (55±17 years) and iii (63±17 years) (P=.03). Esophageal symptoms did not differ between subtypes regarding the severity of nausea, chest pain, coughing, and heartburn, except for increased vomiting severity in subtype i (2.8±1.4 vs. 1.4±1.4 vs. 1.2±1.2, P<.01). A significant radiographic difference in esophageal dilation was seen between subtypes ii and iii (35.1±14.4 vs. 24.0±7.2mm, P=.023). Stasis scores did not significantly differ between the subtypes.

CONCLUSIONS

Achalasia subtypes had similar clinical symptoms, except for increased vomiting severity in subtype i. The maximum esophageal diameter in subtype ii was significantly greater than in subtype iii. Esophageal stasis scores were similar. Thus, high-resolution esophageal manometry remains essential in assessing achalasia subtypes.

Oesophageal disease: gastroesophageal reflux disease, Barrett's oesophagus, achalasia and eosinophilic oesophagitis

The most interesting conclusions and/or advances presented at Digestive Disease Week 2016 were the following: a) gastroesophageal reflux disease: proton pump inhibitor-refractory reflux disease is frequently associated with poor treatment adherence, psychiatric comorbidities and functional gastrointestinal disorders. These possible entities should be investigated in all cases of proton pump inhibitor-refractory reflux disease; b) Barrett's oesophagus: the efficacy of screening remains unclear; however, new minimally-invasive techniques such as the cytosponge allow more effective detection, both of Barrett's oesophagus and Barrett's oesophagus-associated dysplasia or neoplasia; c) achalasia: evidence indicates that peroral endoscopic myotomy is as effective as surgery and is a safer alternative; d) eosinophilic oesophagitis: high-dose proton pump inhibitors are required to rule out proton pump inhibitor-responsive eosinophilic oesophagitis; montelukast is not clearly effective in the treatment of eosinophilic oesophagitis, although moderate efficacy cannot be ruled out.

[Oesophageal diseases: gastroesophageal reflux disease, Barrett's disease, achalasia and eosinophilic oesophagitis]

The most important novel findings presented on oesophageal disease in DDW 2015 were the following: 1) GERD: a) hypervigilance seems to be a key pathogenic factor in reflux symptoms refractory to PPI; b) post-reflux swallowing-induced peristaltic waves could be an excellent diagnostic criterion for GERD; c) laryngeal pH-metry is not useful in the diagnosis of extra-oesophageal symptoms; d) the recommendation of weight loss adequately recorded in the clinical reports of patients with GERD and obesity or overweight is an excellent quality indicator and is associated with better outcomes. 2) Barrett's oesophagus: a) persistent low-grade dysplasia in more than one endoscopy and a diagnosis of "indefinite for dysplasia" are associated with a high risk of neoplastic progression; b) narrow-band imaging allows areas of dysplasia on Barrett's oesophagus to be identified with high sensitivity and specificity; c) initial endoscopy fails to identify a high percentage of advanced neoplasms in Barrett's oesophagus. Early re-endoscopy should be considered; d) endoscopists specialized in Barret's oesophagus obtain a much higher yield in the diagnosis of advanced lesions. Patients at high risk-men, older patients, smokers and those with long-segment Barrett's oesophagus-could benefit from follow-up in a referral center. 3) Achalasia: POEM seems safe and effective, independently from patient characteristics (age, comorbidity) and the technical variations used. 4) Eosinophilic esophagitis: topical budesonide and exclusion diets are reasonably effective in PPI non-responders.

Clinical assessment and health-related quality of life in patients with non-cardiac chest pain

INTRODUCTION

Non-cardiac chest pain (NCCP) is mainly related to oesophageal disease, and in spite of being a common condition in Mexico, information regarding it is scarce.

AIM

To assess the clinical characteristics and health-related quality of life of patients with NCCP of presumed oesophageal origin.

MATERIAL AND METHODS

Patients with NCCP of presumed oesophageal origin with no previous treatment were included in the study. Associated symptoms were assessed and upper gastrointestinal endoscopy and 24-hour oesophageal pH monitoring were performed to diagnose gastroesophageal reflux disease, while oesophageal manometry was used to determine oesophageal motility disorders. The SF-36 Health-Related Quality of Life (HR-QoL) questionnaire was completed and its results compared to a control group without oesophageal symptoms.

RESULTS

The study included 33 patients, of which 61% were women, and the mean age was 46.1 (±11.6) years. Causes of NCCP were gastroesophageal reflux disease in 48%, achalasia in 34%, and functional chest pain in 18%. The average progression time for chest pain was 24 (2-240) months, with ≤ 3 events/week in 52% of the patients. The most frequent accompanying symptoms were: regurgitation (81%), dysphagia (72%) and heartburn (66%). Patients with NCCP show deterioration in HR-QoL compared to the control group (P=.01), regardless of chest pain aetiology. The most affected areas were general perception of health, emotional issues, and mental health sub-scale (P>0.05).

CONCLUSIONS

In our population, patients with NCCP show deterioration in HR-QoL regardless of the aetiology, frequency, and accompanying symptoms.

[Esophageal diseases: GERD, Barrett, achalasia and eosinophilic esophagitis]

At Digestive Disease Week (DDW) 2014, developments in esophageal disease were presented. Highlights include: the usefulness of impedancemetry to diagnose reflux disease, or the effectiveness of PPIs for treating non-cardiac chest pain. Concerning Barrett's esophagus, its prevalence is identical in patients with and without reflux symptoms, Barrett segments less than 1cm probably do not require follow-up, and in older patients with long-segment Barrett, initial endoscopies overlooked up to 2% of significant lesions. Regarding achalasia, surgical myotomy is no more effective than endoscopic dilation and may even be less effective than peroral endoscopic myotomy (POEM). In terms of eosinophilic esophagitis, it is important to systematically take biopsies in patients with dysphagia so that cases of eosinophilic esophagitis are not overlooked. In addition, for this condition, routine endoscopic dilations not only do not seem useful in improving the course of the disease, but could also worsen the response to medical treatment.

[Laparoscopic approach of achalasia. Long-term clinical and functional results and quality of life]

INTRODUCTION

Laparoscopic Heller myotomy has become the gold standard procedure for patients with achalasia. This study evaluates the clinical status, quality of life, and functional outcomes after laparoscopic Heller myotomy.

MATERIAL AND METHODS

We analyzed patients who underwent laparoscopic Heller myotomy with an associated anti-reflux procedure from October 1998 to December 2010. Before surgery, we administered a clinical questionnaire and as of 2002, we also evaluated quality of life using a specific questionnaire (GIQLI). In 2011, we performed a follow up for all available patients. We administered the same clinical questionnaire and quality of life test as before surgery and performed manometry and 24-hour pH monitoring. According to the length of follow up, patients were divided into 3 groups. Group 1 with a follow-up between 6 and 47 months; group 2 follow-up between 48 and 119 months, and group 3 with a follow-up of more than 120 months). Moreover, 27 patients had already been evaluated with this same protocol in 2003. Pre- and postoperative data were compared for the 3 groups and for patients who completed follow up in 2003 and 2011.

RESULTS

Ninety-five patients underwent laparoscopic Heller myotomy. Seventy-six (80%) were available for follow-up. Mean follow-up was 56 months (range 6-143). Global improvement in dysphagia was 89%. Total DeMeester score decreased in the 3 groups. GIQLI scores improved after surgery, reaching normal values. Manometric determinations showed normal LES pressures after myotomy in the 3 groups. Ten percent of overall 24-hour pH monitoring was abnormal. The group of patients followed up in 2003 and in 2011 showed no impairment in the variables studied in the long term.

CONCLUSIONS

Long-term follow up of the laparoscopic approach to achalasia showed good results concerning clinical status and quality of life, with normal sphincteric pressures and a low incidence of gastroesophageal reflux.