Correlation between manometric findings and clinical response in achalasia: A systematic review

Abstract

Objective: To evaluate the correlation between manometric subtypes of achalasia defined by high-resolution esophageal manometry (HRM) and lower esophageal sphincter (LES) distensibility measured by EndoFLIP, analyzing how these parameters relate to clinical response to the main available treatments (POEM, Heller myotomy and pneumatic dilation).

Methods: A systematic review was conducted following the PRISMA 2020 Statement. The search was performed in PubMed and SciELO, covering the period 2015–2024. Twenty-one studies were included that evaluated adult patients (≥18 years) with achalasia confirmed by HRM and that reported clinical outcomes after treatment.

Results: Narrative synthesis showed that subtype II had the best rates of clinical improvement, regardless of the technique used, owing to preservation of panesophageal pressurization capacity. In contrast, subtype III showed a better outcome with POEM, as this technique allows an extended myotomy toward the spastic segments of the esophageal body. Likewise, use of EndoFLIP showed that a moderate increase in LES distensibility is associated with symptom relief, whereas excessive distensibility increases the risk of gastroesophageal reflux.

Conclusion: The evidence supports an individualized therapy approach based on the integration of HRM and EndoFLIP to optimize treatment choice according to physiological subtype and reduce postoperative complications.