Barron John O, Jain Nethra, Toth Andrew J, Moon Soon, Blackstone Eugene H, Tasnim Sadia, Sanaka Madhusudhan, Sudarshan Monisha, Baker Mark E, Murthy Sudish C, Raja Siva
Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-133, Cleveland, OH, 44915, USA.
Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA.
Surg Endosc. 2025 Jan;39(1):480-491. doi: 10.1007/s00464-024-11200-3. Epub 2024 Oct 14.
Current classification of achalasia does not account for variability in esophageal tortuosity. The esophageal length-to-height ratio (LHR) was developed to objectively quantify tortuosity, based on the premise that the esophagus must elongate to become tortuous. Hence, we assess the relationship of esophageal tortuosity, measured by LHR, to preoperative patient characteristics and post-myotomy outcomes, including longitudinal symptom relief and esophageal emptying.
From 01/2014 to 01/2020, 420 eligible adult patients underwent myotomy for achalasia at our institution, 216 (51%) Heller myotomy and 204 (49%) per-oral endoscopic myotomy. LHR was measured on pre- and first postoperative timed barium esophagram (TBE), with larger values signifying greater tortuosity. Variable predictiveness and risk-adjusted longitudinal estimates of symptom relief (Eckardt score ≤ 3) and complete emptying, in relation to LHR and manometric subtype, were estimated.
Median [15th, 85th percentile] preoperative LHR was 1.04 [1.01, 1.10]. Preoperative esophageal width > 3 cm and age > 68 years were most predictive of increased LHR. Increased LHR corresponded with decreases in longitudinal postoperative symptom relief and complete esophageal emptying, with a 4% difference in symptom relief and 20% difference in complete emptying, as LHR increased from 1.0 to 1.16. After adjusting for patient factors, including LHR, manometric subtype was less predictive of symptom relief, with estimated symptom relief occurring in 4% fewer patients with Type III achalasia, compared to Types I and II. Overall, LHR decreased following myotomy in patients with an initially tortuous esophagus.
Length-to-height ratio was the only variable highly predictive of both longitudinal post-myotomy symptom relief and complete esophageal emptying, whereas manometric subtype was less predictive. These findings highlight the importance of tortuosity in the treatment of patients with achalasia, suggesting that inclusion of esophageal morphology in future iterations of achalasia classification is warranted.
贲门失弛缓症的现行分类未考虑食管迂曲度的变异性。食管长度与高度比（LHR）的提出是基于食管必须伸长才会变得迂曲这一前提，用于客观量化迂曲度。因此，我们评估了通过LHR测量的食管迂曲度与术前患者特征及肌切开术后结局之间的关系，包括纵向症状缓解和食管排空情况。
2014年1月至2020年1月，420例符合条件的成年患者在我院接受了贲门失弛缓症肌切开术，其中216例（51%）接受了Heller肌切开术，204例（49%）接受了经口内镜肌切开术。在术前及术后首次定时钡剂食管造影（TBE）上测量LHR，数值越大表明迂曲度越大。评估了与LHR和测压亚型相关的症状缓解（埃卡德特评分≤3）和完全排空的可变预测性及风险调整纵向估计值。
术前LHR的中位数[第15百分位数，第85百分位数]为1.04[1.01，1.10]。术前食管宽度>3 cm和年龄>68岁最能预测LHR升高。LHR升高与术后纵向症状缓解及食管完全排空的降低相关，随着LHR从1.0增至1.16，症状缓解差异为4%，完全排空差异为20%。在调整包括LHR在内的患者因素后，测压亚型对症状缓解的预测性较低，与I型和II型相比，III型贲门失弛缓症患者中估计出现症状缓解的人数少4%。总体而言，初始食管迂曲的患者在肌切开术后LHR降低。
长度与高度比是肌切开术后纵向症状缓解和食管完全排空的唯一高度预测变量，而测压亚型的预测性较低。这些发现突出了迂曲度在贲门失弛缓症患者治疗中的重要性，表明在贲门失弛缓症分类的未来版本中纳入食管形态是有必要的。
