A controversy that has been tough to swallow: is the treatment of achalasia now digested?

Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial

BACKGROUND AND AIMS

The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3 cm) and long (≥6 cm) esophageal myotomy in patients with type I and II achalasia cardia.

METHODS

This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3 cm) and long (≥6 cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1 mo), and gastroesophageal reflux disease (3 mo) between the groups.

RESULTS

Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively ( P =0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36 cm in the SM and 6.69±1.35 cm in the LM groups ( P <0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes ( P <0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment.

CONCLUSIONS

Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up ( P >0.05). Short myotomy resulted in a reduced operative time ( P <0.05).

Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes

PURPOSE

To investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia.

METHODS

We conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility.

RESULTS

Among 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter  > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia.

CONCLUSIONS

Many risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.

Childhood esophageal achalasia: Case report from Afghanistan with literature review

Introduction and importance

Esophageal achalasia is a motility disorder of the esophagus with unknown etiology characterized by the failure of lower esophageal sphincter relaxation. Diagnosis is made by barium esophagography, endoscopy, and esophageal manometery. Heller Esophagomyotomy along with Dor's fundoplication is the treatment of choice. Persisting undiagnosed cases may lead to malnutrition.

Case presentation

We present a case of an 8-year-old child suffering from dysphagia and regurgitation. The child was misdiagnosed and maltreated for the suspicion of respiratory tract and gastrointestinal problems in the local clinics. During this time, he remained unresponsive to the mentioned treatments, and the local physician advised him to have an upper gastrointestinal (GI) endoscopy, which revealed esophageal achalasia (EA).

On admission to our pediatric surgery ward, the patient had coexistent parotitis, which was treated conservatively. Following recovery, the patient was prepared for surgery and underwent esophageal myotomy along with Dor's fundoplication.

Clinical discussion

Esophageal achalasia is rare in children, but poses major health challenges to children if left untreated. Symptomatic treatment may mask the actual picture of the problem and last for years. Following surgery and discharge from the hospital in a three-month follow-up interval of time, our patient exhibited full recovery, with gaining 4 kg weight.

Conclusions

Respiratory and gastrointestinal conditions with similar signs and symptoms should always be considered in differential diagnosis of esophageal achalasia, especially where there is no direct access to a pediatric specialized complex. On-time evaluation and treatment will further prevent children from malnutrition in long-lasting undiagnosed patients.

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Esophageal achalasia is a motility disorder with unknown etiology.

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Esophageal achalasia is rare in children.

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Dysphagia and respiratory infection will mask the actual picture of the problem.

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Unprofessional symptomatic treatment for a long time is the main cause of undiagnosed patient and may lead to malnutrition.

Surgical Management of Advanced Achalasia With Sigmoid Esophagus: A Case Report

The surgical management of achalasia with sigmoid esophagus involves multiple significant challenges due to the difficulty in endoscopic assessment, esophageal motility disorders, and potential complication and recurrence rates. We report a 34-year-old female with worsening dysphagia and malnourishment due to advanced achalasia. An esophagogastroduodenoscopy (EGD) revealed an esophageal dilation, tortuosity, and distal blockage with undigested food. Esophagram demonstrated the typical bird beak appearance with a tortuous dilated esophagus. She underwent a laparoscopic Heller myotomy with Dor fundoplication with no complications. She was discharged on the second postoperative day, tolerating clear liquids, and then a normal diet within six weeks. Several treatment options exist for the surgical management of a sigmoid esophagus with achalasia, but there is no clear gold standard. In our case, Heller myotomy with Dor fundoplication provided favorable results, but treatment should be individualized for each case.

Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response

Background and study aims  The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods  This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %-49 %), 3 (50 %-89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm ² /mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results  Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2-4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2-4 (95.7 % vs. 60 %, P  = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions  Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

Treatment challenges of sigmoid-shaped esophagus and severe achalasia

Background

Achalasia is a chronic motility disorder which may require surgical interventions to effectively manage patients’ symptoms and improve functional status. In late stage achalasia, patients may present with sigmoid-shaped esophagus which complicates traditional treatment approaches for achalasia as the esophagus is massively dilated and dysfunctional with delicate tissue integrity. Severe Achalasia with sigmoid esophagus imposes significant challenge to surgeons and treating physicians. Various assessment modalities and treatment approaches have been tried. Surgical treatment continues to be controversial. Some have argued that a less aggressive approach similar to that in early Achalasia results in satisfactory outcomes. Others have argued a more aggressive approach of esophagectomy is necessary. We present a review of the challenges encountered in each approach with recommendation for selecting the right treatment for the individual cases.

Conclusions

Different treatment options for sigmoid type achalasia are available with ongoing controversy among the options. Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes.

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Late stage achalasia may present with sigmoid-shaped esophagus.

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Sigmoid shaped esophagus imposes significant treatment challenges due to dilation and delicate tissue integrity.

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Surgical treatment continues to be controversial.

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Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes.

Sigmoid megaesophagus with thoracic pseudotumor appearance

A 61-year-old man presented with dysphagia, weight loss and shortness of breath. On examination, he had reduced lung sounds on the right, and obvious neck vein distention. Chest X-ray raised a suspicion of lung tumor with possible superior vena cava syndrome. Subsequent CT scan of chest confirmed the presence of markedly dilated and tortuous esophagus (sigmoid megaesophagus) extending to the right hemithorax and pressing on the trachea. The patient was referred for surgery.

Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial

BACKGROUND

Our prior randomized controlled trial of Heller myotomy alone versus Heller plus Dor fundoplication for achalasia from 2000 to 2004 demonstrated comparable postoperative resolution of dysphagia but less gastroesophageal reflux after Heller plus Dor. Patient-reported outcomes are needed to determine whether the findings are sustained long-term.

METHODS

We actively engaged participants from the prior randomized cohort, making up to six contact attempts per person using telephone, mail, and electronic messaging. We collected patient-reported measures of dysphagia and gastroesophageal reflux using the Dysphagia Score and the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) instrument. Patient-reported re-interventions for dysphagia were verified by obtaining longitudinal medical records.

RESULTS

Among living participants, 27/41 (66%) were contacted and all completed the follow-up study at a mean of 11.8 years postoperatively. Median Dysphagia Scores and GERD-HRQL scores were slightly worse for Heller than Heller plus Dor but were not statistically different (6 vs 3, p = 0.08 for dysphagia, 15 vs 13, p = 0.25 for reflux). Five patients in the Heller group and 6 in Heller plus Dor underwent re-intervention for dysphagia with most occurring more than five years postoperatively. One patient in each group underwent redo Heller myotomy and subsequent esophagectomy. Nearly all patients (96%) would undergo operation again.

CONCLUSIONS

Long-term patient-reported outcomes after Heller alone and Heller plus Dor for achalasia are comparable, providing support for either procedure.

Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials

BACKGROUND

Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM.

METHODS

A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed.

RESULTS

A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34).

CONCLUSION

PD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Esophageal Achalasia: Predictive Value of Preoperative Resting Pressure of LES Correlated with Type of Fundoplication

OBJECTIVE

The aim of the present study is to show the predictive value of the preoperative resting pressure of the lower esophageal sphincter (LES) correlated with the type of fundoplication (Nissen or Dor) after Heller myotomy in our series.

MATERIALS AND METHODS

From January 1998 to June 2010, 88 patients affected by esophageal achalasia underwent surgery at our unit. However, our study focused on a sample of 36 patients, because many data were lost or was never recorded. Among these, 14 patients underwent laparoscopic Heller myotomy plus Nissen fundoplication (group N), whereas 22 patients underwent laparoscopic Heller myotomy plus Dor fundoplication (group D). Clinical evaluation was performed using a modified DeMeester symptom scoring system consisting of the assessment of three symptoms: dysphagia, regurgitation, and heartburn. To each symptom was assigned a score from 0 to 3, depending on its severity, and the reduction in the severity of each symptom after surgery was assessed.

RESULTS

The surgical treatment is considered to be effective (p<0.0001). The preoperative resting pressures of LES were compared by Student's t-test, and it was found that patients who reported a greater improvement in the dysphagia symptom had a preoperative average pressure of LES that was significantly higher than that in other patients in both group N (p=0.03) and group D (p=0.01; p=0.003; p=0.001). The Dor treatment was shown to be more effective than the Nissen treatment (p<0.0001).

CONCLUSION

The preoperative resting pressure of LES is a predictive factor of surgical success both before Dor fundoplication and before Nissen fundoplication, but its predictive power is influenced by the chosen type of fundoplication.

Mucosal perforation during laparoscopic surgery for achalasia: impact of preoperative pneumatic balloon dilation

BACKGROUND

Controversy remains whether preoperative pneumatic balloon dilation (PBD) influences the surgical outcome of laparoscopic esophagocardiomyotomy in patients with esophageal achalasia. The aim of this study was to evaluate whether preoperative PBD represents a risk factor for surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD).

METHODS

A retrospective chart review was conducted on a prospectively compiled surgical database of 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): (1) patients' demographics: age, gender, body mass index, duration of symptoms, maximum transverse diameter of esophagus; (2) operative findings: operating time, blood loss, intraoperative complications; (3) postoperative course: complications, clinical symptoms, postoperative treatment; and (4) esophageal functional tests: preoperative and postoperative manometric data and postoperative profile of 24-h esophageal pH monitoring.

RESULTS

(1) No significant differences were observed in the patients' demographics. (2) Operative findings were similar between the two groups; however, the incidence of mucosal perforation was significantly higher in the PBD group (n = 8; 30.7 %) compared to the non-PBD group (n = 6; 7.7 %) (p = 0.005). (3) Postoperative complications were not encountered in either group. The differences were not significant for postoperative clinical symptoms, the incidence of gastroesophageal reflux disease, or necessity of postoperative treatments. (4) Lower esophageal sphincter pressure was effectively reduced in both groups, and no differences were observed in manometric data or 24-h pH monitoring profiles between the two groups. Multivariate logistic regression analysis showed that preoperative PBD and the maximum transverse diameter of esophagus were significantly associated with intraoperative mucosal perforation.

CONCLUSIONS

Although postoperative outcomes were not affected, additional caution is recommended in identifying intraoperative mucosal perforation in patients with preoperative PBD when performing LHD.

Laparoscopic esophagomyotomy for achalasia in children: A review

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.

Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study

BACKGROUND

This study compares the long-term results of pneumatic dilatations versus laparoscopic myotomy using treatment failure as the primary outcome. The frequency and degree of dysphagia, the effects on quality of life (QoL), and health economy were also examined.

METHODS

Fifty-three patients with achalasia were randomized to laparoscopic myotomy with a posterior partial fundoplication [laparoscopic myotomy (LM) n = 25] or repetitive pneumatic dilatation [pneumatic dilatation (PD) n = 28]. The median observation period was 81.5 months (range 12-131).

RESULTS

At the minimal follow-up of 5 years, ten patients (36%) in the dilatation group and two patients (8%) in the myotomy group, including two patients lost to follow-up (one in each arm), were classified as failures (p = 0.016). The cumulative incidence of treatment failures was analyzed by survival statistics. Taking the entire follow-up period into account, a significant difference was observed in favor of the LM strategy (p = 0.02). Although both treatments resulted in significant improvements in dysphagia scores, LM was significantly favored over PD after 1 and 3 years, but not after 5 years. Health-related QoL assessed by the personal general well being score was higher in the LM group after 3 years, but the difference was not fully statistically significant at 5 years. Direct medical costs during the entire follow-up period were in median $13,421 for LM as compared to $5,558 for PD (p = 0.001).

CONCLUSIONS

This long-term follow-up of a randomized clinical study shows that LM is superior to repetitive PD treatment of newly diagnosed achalasia, albeit that this surgical strategy is burdened by high initial direct medical costs. www.ClinicalTrials.gov NCT 02086669.

Fundoplication after heller myotomy: a retrospective comparison between nissen and dor

OBJECTIVE

A retrospective comparison between Nissen and Dor fundoplication after laparoscopic Heller myotomy for achalasia.

MATERIALS AND METHODS

From 1998 to 2004 a first group of 48 patients underwent Heller myotomy and Nissen fundoplication for idiopathic achalasia (H+N group). From 2004 to 2010 a second group of 40 patients underwent Heller myotomy followed by Dor fundoplication (H+D group). Some patients received a previous endoscopic treatment with pneumatic dilatation or endoscopic injection of botulinum toxin that provided them only a temporary clinical benefit. Changes in clinical and instrumental examinations from before to after surgery were evaluated in all patients. Clinical evaluation was carried out using a modified DeMeester symptom score system.

RESULTS

Dor fundoplication treatment reduced both dysphagia and regurgitation severity scores significantly more than Nissen fundoplication (p<0.0001). Indeed, the incidence of dysphagia was significantly higher in patients treated with floppy-Nissen than in those treated with Dor fundoplication: by defining dysphagia as a DeMeester score equal to 3 (arbitrary cut-off), at the end of follow-up dysphagia occurred in 17.65% and 0% (p=0.037) of patients belonging to the H+N and H+D groups, respectively.

CONCLUSION

Heller myotomy followed by Dor fundoplication is a safe and valuable treatment. The procedure showed a lower incidence of postoperative dysphagia versus Nissen fundoplication and a negligible incidence of postoperative GERD in a long-term postoperative follow-up.

National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events

INTRODUCTION

Laparoscopic Heller myotomy (LHM) has supplanted an open approach due to decreased operative morbidity. Our goal was to quantify the incidence of peri-operative complications and identify risk factors for adverse outcomes in LHM.

METHODS

All LHM were queried from 2005 to 2011 from the National Surgical Quality Improvement Program database. Adverse outcomes were identified, and univariate and stepwise logistic regression (MVR) was then performed to quantify association.

RESULTS

There were 1,237 LHM in the study period. Patient averages were: age 51.9 ± 16.8 years, BMI 27.3 ± 6.6 kg/m(2), Charlson comorbidity index (CCI) 0.2 ± 0.6. 15.3 % had >10 % body mass loss in the preoperative 6 months. During surgery, 10.2 % underwent concomitant EGD, and mean operative time was 141.6 ± 63.4 min. There were 7(0.06 %) wound complications, 22(1.8 %) general complications, and 30(2.4 %) major complications. Average length of stay (LOS) was 2.8 ± 5.5 days. The rate of readmission and reoperation were 3.1 and 2.3 %, respectively, and there were 4(0.03 %) deaths. General and major complications were associated with alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times (p < 0.05); however, these factors did not remain significant on MVR (p > 0.05). Operative time was found to be significantly longer by 35.3 min for inpatients, 43.1 min in functionally dependent patients, 50.0 min in preoperative septic patients, and 17.2 min with concomitant EGD (p < 0.01 for all). LOS was found to be longer by 1.9 days for inpatients, 1.8 days in ASA category ≥3, and 1.2 days per one point increase in CCI (p < 0.001 for all).

CONCLUSION

LHM is being performed nationally with a low incidence of operative complications and mortality. General and major complications following LHM are associated with patient alcohol use, pack-years of smoking, weight loss, history of stroke, radiation therapy, and longer operative times. Additionally, independent predictors of longer operative time and LOS were identified.

Surgical treatment of infantile achalasia: a case report and literature review

Allgrove syndrome is a rare genetic disorder typically manifested by alacrima, achalasia, and adrenal insufficiency, and is one of the rare causes of achalasia in infants. While the gold standard for achalasia treatment in adults is an esophageal myotomy with fundoplication, a standard treatment for infantile achalasia remains undetermined due to the low number of reported cases and rarity of the disease in this age group. We report a 7.7 kg infant with achalasia secondary to Allgrove syndrome who was successfully treated by Heller myotomy and simultaneous Toupet fundoplication. This case represents one of the smallest patients to ever be treated for achalasia and highlights the role that primary surgical therapy may have for the infantile variant of the disease.

New endoscopic classification of achalasia for selection of candidates for peroral endoscopic myotomy

AIM: To propose a new endoscopic classification of achalasia for selecting patients appropriate for undergoing peroral endoscopic myotomy (POEM).

METHODS: We screened out the data of patients with achalasia examined from October 2000 to September 2011 at our Digestive Endoscopic Center with endoscopic pictures clear enough to reveal the morphology of middle and lower esophagus. After analyzing the correlation between the endoscopic morphology of the esophageal lumen and POEM, we proposed a new endoscopic classification (Ling classification) of achalasia according to three kinds of endoscopically viewed structures: multi-ring structure, crescent-like structure and diverticulum structure. There were three types based on the criteria of Ling classification: type I, smooth without multi-ring, crescent-like structure or diverticulum structure; type II, with multi-ring or crescent-like structure but without diverticulum structure; and type III, with diverticulum structure. Type II was classified into three subtypes: Ling II_a, Ling II_b and Ling II_c; and type III also had three subtypes: Ling III_l, Ling III_r and Ling III_lr. Two endoscopists made a final decision upon mutual agreement through discussion if their separately recorded characteristics were different.

RESULTS: Among the 976 screened patients with achalasia, 636 patients with qualified endoscopic pictures were selected for the analysis, including 405 males and 231 females. The average age was 42.7 years, ranging from 6 to 93 years. Type I was the most commonly observed type of achalasia, accounting for 64.5% (410/636), and type III was the least commonly observed type of achalasia, accounting for 2.8% (18/636). And type II accounted for 32.7% (208/636) and subtype of Ling II_a, Ling II_b and Ling II_c accounted for 14.6% (93/636), 9.9% (63/636) and 8.2% (52/636), respectively. And subtype of Ling III_l, Ling III_r and Ling III_lr accounted for 0.8% (5/636), 0.3% (2/636) and 1.7% (11/636), respectively.

CONCLUSION: A new endoscopic classification of achalasia is proposed that might help in determining the proper candidates for POEM.