Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients

Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group (P < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group (P < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients (P = n.s.). Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.