[Esophageal Achalasia after Surgery for Lung Cancer]

A 61-year-old man was admitted to our hospital for an abnormal chest shadow. Computed tomography (CT) showed a pulmonary nodular shadow in the right middle lobe. He was diagnosed with stage cT2aN0M0 (IB) pulmonary adenocarcinoma and was treated with surgery of right middle lobectomy and mediastinal lymph node dissection. On 2nd day after surgery, he got aspiration pneumonia. CT showed consolidation of left lower lobe, stenosis of lower esophagus with dilation of the oral side and stagnation of residual foods. Esophagogram showed stenosis of the lower esophagus and stagnation of the contrast medium. He was diagnosed with esophageal achalasia. Balloon dilation was performed and the obstruction was improved. He has been well without recurrence of achalasia.

Esophageal Achalasia: Pathophysiology, Clinical Presentation, and Diagnostic Evaluation

Esophageal achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter to relax in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with resulting food stasis. Most patients experience severe dysphagia, and regurgitation can lead to aspiration and respiratory problems. Consequently, the quality of life of patients affected by achalasia is severely impacted. A thorough evaluation with upper endoscopy, barium swallow, and esophageal manometry is mandatory to establish the diagnosis and plan the optimal treatment. In selected patients, an ambulatory pH monitoring is recommended to distinguish between gastroesophageal reflux disease and achalasia.

Esophageal transit time in patients with chagasic megaesophagus: Lack of linear correlation between dysphagia and grade of dilatation

The aim of this study was to determine the esophageal transit time in control individuals and in chagasic patients with or without megaesophagus.A total of 148 patients were allocated in 6 groups according to serological diagnostic of Chagas disease and the degree of esophageal dilatation: A, control healthy individuals (n = 34, 22.9%); B, indeterminate form (n = 23, 15.5%); C, megaesophagus I (n = 37, 25.0%); D, megaesophagus II (n = 19, 12.8%); E, megaesophagus III (n = 21, 14.2%); and F, megaesophagus IV (n = 14, 9.5%). After 8-hour fasting, patients were asked to swallow 75 mL of barium sulfate solution. x-Rays were obtained after 8, 30, 60, and 90 seconds, 5, 10, 30, 60, and 90 minutes, 2, 6, 12, 24 hours, and at every 12 hours until no more contrast was seen in the esophagus. This was the transit time.The transit time varied from 8 seconds to 36 hours (median = 90 seconds). A linear correlation was observed between transit time and megaesophagus grade: 8 seconds in groups A and B, 5 minutes in C, 30 minutes in D, 2 hours in E, and 9:15 hours in F. Dysphagia was not reported by 60 of 114 (52.6%) patients with positive serological tests for Chagas disease (37/91-40.7%-of patients with megaesophagus I-IV grades). The esophageal transit time increased with the grade of megaesophagus.The esophageal transit time has a direct correlation with the grade of megaesophagus; dysphagia complaint correlates with the grade of megaesophagus. However, many patients with megaesophagus do not report dysphagia.

Achalasia after bariatric Roux-en-Y gastric bypass surgery reversal

Achalasia is a rare esophageal motility disorder that is characterized by a loss of peristalsis in the distal esophagus and failure of lower esophageal sphincter relaxation. The risk of developing esophageal motility disorders, including achalasia, following bariatric surgery is controversial and differs based on the type of surgery. Most of the reported cases occurred with laparoscopic adjustable gastric banding. To our knowledge, there are only three reported cases of achalasia after Roux-en-Y gastric bypass and no reported cases after revision of the surgery. We present a case of a 70-year-old female who had a previous history of Roux-en-Y gastric bypass with revision. She presented with persistent nausea and regurgitation for one month. Esophagogastroduodenoscopy showed a dilated esophagus without strictures or stenosis. A barium study was performed after the endoscopy and was suggestive of achalasia. Those findings were confirmed by a manometry. The patient was referred for laparoscopic Heller’s myotomy.

Peroral endoscopic myotomy for treatment of Guillain-Barre syndrome-associated achalasia: A rare case

Guillain-Barre syndrome (GBS)-associated achalasia is a very rare disease of uncertain cause. We report the case of a patient diagnosed with GBS-associated type I achalasia who was successfully treated with peroral endoscopic myotomy (POEM). A 30-year-old man who was diagnosed with GBS 3 mo before was referred to our department with dysphagia and meal-related regurgitation. The results of esophagography, endoscopy, and high-resolution manometry (HRM) revealed type I achalasia. POEM that utilized a submucosal tunneling technique was performed to treat the GBS-associated type I achalasia. After POEM, smooth passage of a contrast agent into the stomach was shown in follow-up esophagography, and follow-up HRM revealed a decrease in the mean integrated relaxation pressure 22.9 mmHg to 9.6 mmHg. The patient remained without dysphagia for 7 mo, even though the patient’s neurological problems were not fully resolved. POEM may be a safe and effective treatment for GBS-associated type I achalasia.

Pyopericardium secondary to achalasia-associated squamous cell carcinoma of the oesophagus

Patients with achalasia of the oesophagus are known to be at increased risk of oesophageal squamous cell carcinoma. To our knowledge, this is the first report of an achalasia-associated oesophageal squamous cell carcinoma presenting with acute sepsis secondary to pyopericardium.

Idiopathic hypereosinophilic syndrome presenting with hepatitis and achalasia

Idiopathic hypereosinophilic syndrome (HES) is a rare diagnosis defined by the World Health Organization as a persistent eosinophilia for 6 months and resulting in end-organ dysfunction. While many patients present with nonspecific symptoms, others will present with symptoms of the affected organs, most commonly those involving the heart, skin, or nervous system. Gastrointestinal or liver involvement is estimated to affect up to one-third of patients with HES, although patients with clinically significant disease are limited to case reports. This is the first report of a patient presenting with hepatitis and achalasia related to idiopathic HES.

[A Case of Squamous Cell Carcinoma of the Esophagus with Achalasia -- Conversion from Chemoradiotherapy to Surgery]

The patient was a 67-year-old woman with achalasia and squamous cell carcinoma(SCC)of the esophagus. She presented with a difficulty in swallowing. The cancer was on the surface of the esophagus. The patient initially received systemic chemotherapy with 5-FU and cisplatin, and radiation therapy. The difficulty in swallowing persisted due to insufficiency of radiation treatment caused by achalasia. Therefore, we shifted the treatment plan from chemoradiotherapy to surgery. Endoscopic examination performed before surgery showed that there was no obvious cancer in the esophagus. We resected the esophagus routinely. On the specimen, no cancer cells were detected upon macroscopic and microscopic examinations; metastasis was not detected in the lymph node. Achalasia is a recognized risk factor for esophageal SCC. In the treatment of superficial SCC, no difference of therapeutic effect was observed between surgery and chemoradiation. However, for the treatment of certain cases of SCC with achalasia, including the treatment of achalasia itself, surgery can be the preferred option of treatment.

Redo Heller Myotomy for Achalasia in a Patient with Down Syndrome: a Case Report

Up to 77% of Down syndrome (DS) patients have associated structural or functional gastrointestinal abnormalities. Functional disturbances, such as processes affecting the enteric nervous system, can often affect the outcome of corrective surgical procedures. Recently, an association between DS and achalasia has been reported. In this report we present a 28-year-old male patient with a history of Down syndrome and achalasia, who presented with recurrent dysphagia, gastroesophageal reflux, and recurrent aspirations. The patient had previously undergone a laparoscopic Heller myotomy with Dor fundoplication. Unfortunately, despite this surgery, he continued to require multiple esophageal dilations, and intraesophageal administration of Botox therapy. Additionally, there were numerous subsequent hospital admissions for recurrent aspiration pneumonia. Evaluation revealed an incomplete myotomy and a revision long Heller myotomy was successfully performed intraabdominally and he is now symptom and aspiration free.

Megaesophagus associated with Myasthenia Gravis: a rare condition in humans

We present the case of a 79 year-old patient with megaesophagus and aphagia, who required percutaneous endoscopic gastrostomy (PEG) feeding. Megaesophagus was considered the sole cause of aphagia by the referring secondary hospital. Solid state sensor videofluoromanometry (VFM) showed a substantial decrease in manometric values within the hypopharynx along with good relaxation of the upper-esophageal sphincter (UES). This led to electromyography (EMG), which showed features compatible with the diagnosis of Myasthenia Gravis (MG). The diagnosis of MG was confirmed by an intravenous injection of edrophonium chloride, performed under VFM monitoring. The co-existence of MG and megaesophagus rarely occurs in humans; although, most small animals, such as dogs, cats, and rodents, present with megaesophagus as an initial symptom of MG.

Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study

BACKGROUND

Surgical Heller myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical myotomy failure is controversial. Recently, peroral endscopic myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence.

STUDY DESIGN

A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM.

RESULTS

The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p < 0.01) and Eckardt symptom scores (6.5 ± 1.3 vs 1.1 ± 1.3, p < 0.001) were observed.

CONCLUSIONS

Short-term results of POEM for failed surgical myotomy were excellent. Long-term results are awaited.

Deficiency of ALADIN impairs redox homeostasis in human adrenal cells and inhibits steroidogenesis

Triple A syndrome is a rare, autosomal recessive cause of adrenal failure. Additional features include alacrima, achalasia of the esophageal cardia, and progressive neurodegenerative disease. The AAAS gene product is the nuclear pore complex protein alacrima-achalasia-adrenal insufficiency neurological disorder (ALADIN), of unknown function. Triple A syndrome patient dermal fibroblasts appear to be more sensitive to oxidative stress than wild-type fibroblasts. To provide an adrenal and neuronal-specific disease model, we established AAAS-gene knockdown in H295R human adrenocortical tumor cells and SH-SY5Y human neuroblastoma cells by lentiviral short hairpin RNA transduction. AAAS-knockdown significantly reduced cell viability in H295R cells. This effect was exacerbated by hydrogen peroxide treatment and improved by application of the antioxidant N-acetylcysteine. An imbalance in redox homeostasis after AAAS knockdown was further suggested in the H295R cells by a decrease in the ratio of reduced to oxidized glutathione. AAAS-knockdown SH-SY5Y cells were also hypersensitive to oxidative stress and responded to antioxidant treatment. A further impact on function was observed in the AAAS-knockdown H295R cells with reduced expression of key components of the steroidogenic pathway, including steroidogenic acute regulatory and P450c11β protein expression. Importantly a significant reduction in cortisol production was demonstrated with AAAS knockdown, which was partially reversed with N-acetylcysteine treatment.

CONCLUSION

Our in vitro data in AAAS-knockdown adrenal and neuronal cells not only corroborates previous studies implicating oxidative stress in this disorder but also provides further insights into the pathogenic mechanisms in triple A syndrome.

Definition, incidence and etiology: what's new in the 21st century?

Actually, achalasia can be defined as a primary esophageal motor disorder characterized by esophageal aperistalsis and abnormal post-deglutitive lower esophageal sphincter (LES) relaxation. Its incidence varies from 0.03 to 1.63 cases per 100,000 people per year and increases with age, while the prevalence is almost 10/100,000 with no difference between the sexes. Regarding etiology, the most frequent histologic alteration is represented by the loss of the myenteric nerve fibers regulating inhibitory nitrergic neurotransmission in the LES, with the presence of a lymphocytic infiltrate and collagen deposition. The cause of this loss remains unclear. Among the theories proposed, the infectious, hereditary and autoimmune etiologies have been widely investigated. The only infectious agent identified as a cause of achalasia is Trypanosoma Cruzi, responsible of Chagas' disease. Regarding hereditary component, in rare cases achalasia presents as part of a genetic syndrome such as Down syndrome, Allgrove syndrome and familial visceral neuropathy. Although, no disease-specific gene has been identified. The autoimmune hypothesis has focused on the association of specific HLA classes with achalasia. However, no consistent association has been observed across studies. Despite increasing understanding of the physiopathology of achalasia, its etiology remains largely unknown. The onset of the disease is characterized by chronic inflammation of the myenteric plexus of the esophagus secondary to an environmental insult. Probably, genetic factors are involved in the development of achalasia, although the precise molecular basis of the disease has not been identified.

[Systemic sarcoidosis and achalasia. Apropos of a case]

Sarcoidosis is a systemic disease that only exceptionally affects the gastrointestinal tract. We report the case of a man with systemic sarcoidosis who developed achalasia revealed by esophageal manometry, barium radiographs and echoendoscopy. No response was obtained with steroid therapy, and finally laparoscopic cardiomyotomy was performed with excellent results.

[Rehabilitation of the patients presenting with oesophageal achalasia following balloon cardiodilation]

The present study involved a total of 25 patients presenting with oesophageal achalasia who had undergone balloon cardiodilation. The complex of rehabilitative measures concluded the application of an ultrahigh-frequency electromagnetic fields (decimeter wave (DMW) therapy) to the collar region and general iodine bromide baths. The treatment resulted in the elimination of dysphagia syndrome during consumption of solid food in 80% of the patients. Simultaneously, the oesophagogastroscopic study revealed the improvement of the state of oesophageal mucosa. Moreover, the thyrotropin level was normalized. The positive effect of such rehabilitative treatment persisted during 6-8 months.

A retrospective and prospective study of megaesophagus in the parma wallaby (Macropus parma) at the San Diego Zoo, California, USA

At the San Diego Zoo (California, USA), 22 cases of megaesophagus were diagnosed in the parma wallaby (Macropus parma), yielding a prevalence of 21.1%. Parma wallabies often have no clinical signs until severe and chronic dilation of the esophagus is present. Clinical signs of advanced disease include weight loss, swelling of the cervical region, regurgitation without reswallowing of ingesta, short flight distance, depression, collapse, dyspnea, and sudden death. Retrospective and prospective studies at the San Diego Zoo and a multi-institutional survey in the United States were used to try to determine the cause of megaesophagus. The retrospective study did not identify an etiology. The prospective study revealed megaesophagus and severely delayed esophageal transit time in eight of eight animals. Myasthenia gravis, lead toxicosis, toxoplasmosis, and thyroid disease were eliminated as possible causes. Of 286 living and dead parma wallabies surveyed at other institutions, three cases of esophageal diverticulum and one case of megaesophagus were reported. The cause of megaesophagus in parma wallabies was not determined.