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Zanini LYK, Herbella FAM, Velanovich V, Patti MG. Modern insights into the pathophysiology and treatment of pseudoachalasia. Langenbecks Arch Surg 2024; 409:65. [PMID: 38367052 DOI: 10.1007/s00423-024-03259-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Secondary achalasia or pseudoachalasia is a clinical presentation undistinguishable from achalasia in terms of symptoms, manometric, and radiographic findings, but associated with different and identifiable underlying causes. METHODS A literature review was conducted on the PubMed database restricting results to the English language. Key terms used were "achalasia-like" with 63 results, "secondary achalasia" with 69 results, and "pseudoachalasia" with 141 results. References of the retrieved papers were also manually reviewed. RESULTS Etiology, diagnosis, and treatment were reviewed. CONCLUSIONS Pseudoachalasia is a rare disease. Most available evidence regarding this condition is based on case reports or small retrospective series. There are different causes but all culminating in outflow obstruction. Clinical presentation and image and functional tests overlap with primary achalasia or are inaccurate, thus the identification of secondary achalasia can be delayed. Inadequate diagnosis leads to futile therapies and could worsen prognosis, especially in neoplastic disease. Routine screening is not justifiable; good clinical judgment still remains the best tool. Therapy should be aimed at etiology. Even though Heller's myotomy brings the best results in non-malignant cases, good clinical judgment still remains the best tool as well.
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Affiliation(s)
- Leonardo Yuri Kasputis Zanini
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, São Paulo, 04037-003, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, São Paulo, 04037-003, Brazil.
| | - Vic Velanovich
- Department of Surgery, University of South Florida, Tampa, USA
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, USA
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Abstract
Background Dysphagia aortica is an umbrella term to describe swallowing obstruction from external aortic compression secondary to a dilated, tortuous, or aneurysmal aorta. We performed a systematic literature review to clarify clinical features and outcomes of patients with dysphagia aortica. Materials and methods We searched PubMed, EMBASE, Web of Science, and the Cochrane Library. The terms “aortic dysphagia,” “dysphagia aortica,” “dysphagia AND aortic aneurysm” were matched. We also queried the prospectively updated database of our esophageal center to identify patients with aortic dysphagia referred for diagnosis and treatment over the past two decades. Results A total of 57 studies including 69 patients diagnosed with dysphagia aortica were identified, and one patient from our center was added to the database. The mean age was 72 years (range 22–98), and the male to female ratio 1.1:1. Of these 70 patients, the majority (n = 63, 90%) had an aortic aneurysm, pseudoaneurysm, or dissection. Overall, 37 (53%) patients received an operative treatment (81.1% a vascular procedure, 13.5% a digestive tract procedure, 5.4% both procedures). Thoracic endovascular aortic repair (TEVAR) accounted for 60% of all vascular procedures. The postoperative mortality rate was 21.2% (n = 7/33). The mortality rate among patients treated conservatively was 55% (n = 11/20). Twenty-six (45.6%) studies were deemed at a high risk of bias. Conclusion Dysphagia aortica is a rare clinical entity with high morbidity and mortality rates and no standardized management. Early recognition of dysphagia and a high suspicion of aortoesophageal fistula may be lifesaving in this patient population.
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Haj Ali SN, Nguyen NQ, Abu Sneineh AT. Pseudoachalasia: a diagnostic challenge. When to consider and how to manage? Scand J Gastroenterol 2021; 56:747-752. [PMID: 34043926 DOI: 10.1080/00365521.2021.1925957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.
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Affiliation(s)
- Sara N Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt, Jordan
| | - Nam Q Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Awni T Abu Sneineh
- Department of Gastroenterology, Jordan University Hospital, Amman, Jordan
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Gergely M, Mello MD, Rengarajan A, Gyawali CP. Duration of symptoms and manometric parameters offer clues to diagnosis of pseudoachalasia. Neurogastroenterol Motil 2021; 33:e13965. [PMID: 32779296 DOI: 10.1111/nmo.13965] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 06/17/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pseudoachalasia manifests high-resolution manometry (HRM) findings of achalasia but results from a secondary process. We analyzed clinical and HRM characteristics of pseudoachalasia, including malignant and non-malignant subtypes. METHODS High-resolution manometry was retrospectively reviewed in patients with confirmed pseudoachalasia, and corroborated with endoscopic and radiographic studies. A control cohort of idiopathic achalasia patients was identified. Clinical characteristics, Eckardt score, and HRM metrics were extracted from institutional records. Grouped data and medians (interquartile range) were compared between pseudoachalasia and idiopathic achalasia, and between malignant and non-malignant pseudoachalasia, using parametric and non-parametric statistical tests. KEY RESULTS Of 28 pseudoachalasia patients (62.2 ± 2.5 years, 60.7% female), 18 (64.3%) had malignancy, and 10 (35.7%) had non-malignant obstruction. Although Eckardt score did not differentiate pseudoachalasia from 58 achalasia patients (55.9 ± 2.5 years, 53.4% female), weight loss was greater (median 9.1 [5.0-18.5] vs 3.6 [0-9.1] kg, P < .02) with shorter duration of symptoms (median 12.9 [8.0-38.6] vs 36.0 [25.7-45.0] weeks, P < .001] in pseudoachalasia. Esophagogastric junction (EGJ) metrics demonstrated lower mean IRP values and lower EGJ contractile integral in pseudoachalasia (P < .04 for each comparison with idiopathic achalasia). Type 1 pattern was more frequent in pseudoachalasia (39.3% vs 13.8%, P < .008). Pseudoachalasia demonstrated incomplete HRM patterns, with lower rates of lack of peristalsis (79.6%, vs 93.1% in achalasia, P < .05). Despite higher Eckardt scores in malignant vs non-malignant pseudoachalasia (median 8.0 [7.0-9.0] vs 6.0 [3.5-7.8], P < .03], no significant HRM differences were noted. CONCLUSIONS AND INFERENCES Pseudoachalasia manifests with a shorter history, greater weight loss, and incomplete HRM achalasia patterns compared to achalasia.
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Affiliation(s)
- Maté Gergely
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Michael D Mello
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Arvind Rengarajan
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
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Mesh-related complications in paraoesophageal repair: a systematic review. Surg Endosc 2020; 34:4257-4280. [PMID: 32556700 DOI: 10.1007/s00464-020-07723-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 06/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Paraoesophageal hernias (PEH) have a high recurrence rate, prompting surgeons to consider the use of mesh reinforcement of the hiatus. The risks and benefits of mesh augmentation in PEH repair are debated. Mesh-related complications including migration and erosion are considered in this publication. DESIGN A systematic literature review of articles published between 1970 and 2019 in Medline, OVID, Embase, and Springer database was conducted, identifying case reports, case series and observational studies of PEH repair reporting mesh-related complications. RESULTS Thirty-five case reports/series of 74 patients and 20 observational studies reporting 75 of 4200 patients with mesh complications have been included. The incidence of mesh-related erosions in this study is 0.035%. PTFE, ePTFE, composite and synthetic meshes were frequently associated with mesh erosion requiring intervention. Complete erosions are often managed endoscopically while partial erosions may require surgery and resection of the oesophagus and/or stomach. CONCLUSIONS Mesh-related complication is rare with dysphagia a common presenting feature. Mesh erosion is associated with synthetic mesh more frequently in the reported literature. A mesh registry with long-term longitudinal data would help in understanding the true incidence of mesh-related complications.
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Ayazi S, DeMeester SR, Hagen JA, Zehetner J, Bremner RM, Lipham JC, Crookes PF, DeMeester TR. Clinical Significance of Esophageal Outflow Resistance Imposed by a Nissen Fundoplication. J Am Coll Surg 2019; 229:210-216. [PMID: 30998974 DOI: 10.1016/j.jamcollsurg.2019.03.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/03/2019] [Accepted: 03/07/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Attention has been focused on the amplitude of esophageal body contraction to avoid persistent dysphagia after a Nissen fundoplication. The current recommended level is a contraction amplitude in the distal third of esophagus above the fifth percentile. We hypothesized that a more physiologic approach is to measure outflow resistance imposed by a fundoplication, which needs to be overcome by the esophageal contraction amplitude. STUDY DESIGN The esophageal outflow resistance, as reflected by the intra-bolus pressure (iBP) measured 5 cm above the lower esophageal sphincter (LES), was measured in 53 normal subjects and 37 reflux patients with normal esophageal contraction amplitude, before and after a standardized Nissen fundoplication. All were free of postoperative dysphagia. A test population of 100 patients who had a Nissen fundoplication was used to validate the threshold of outflow resistance to avoid persistent postoperative dysphagia. RESULTS The mean (SD) amplitude of the iBP in normal subjects was 6.8 (3.7) mmHg and in patients before fundoplication was 3.6 (7.0) mmHg (p = 0.003). After Nissen fundoplication, the mean (SD) amplitude of the iBP increased to 12.0 (3.2) mmHg (p < 0.0001 vs normal subjects or preoperative values). The 95th percentile value for iBP after a Nissen fundoplication was 20.0 mmHg and was exceeded by esophageal contraction in all patients in the validation population, and 97% of these patients were free of persistent postoperative dysphagia at a median 50-month follow-up. CONCLUSIONS Nissen fundoplication increases the outflow resistance of the esophagus and should be constructed to avoid an iBP > 20 mmHg. Patients whose distal third esophageal contraction amplitude is >20 mmHg have a minimal risk of dysphagia after a tension-free Nissen fundoplication.
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Affiliation(s)
- Shahin Ayazi
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Jeffrey A Hagen
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Joerg Zehetner
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - John C Lipham
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Peter F Crookes
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tom R DeMeester
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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Timerbulatov MV, Senderovich EI, Grishina EE, Gimaev EF, Kazakov NM. [Redo surgery after laparoscopic fundoplication]. Khirurgiia (Mosk) 2019:29-35. [PMID: 31626236 DOI: 10.17116/hirurgia201910129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To analyze the results of redo surgeries after previous laparoscopic fundoplication. MATERIAL AND METHODS A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire. RESULTS The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery. CONCLUSION Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.
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Affiliation(s)
| | | | | | - E F Gimaev
- Ufa City Clinical Hospital #21, Ufa, Russia
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Pseudoachalasia secondary to pleural mesothelioma. Eur Surg 2017. [DOI: 10.1007/s10353-017-0509-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Beqari J, Lembo A, Critchlow J, Hamden A, Kent MS. Pseudoachalasia Secondary to Thoracic Aortic Aneurysm. Ann Thorac Surg 2017; 103:e517-e518. [PMID: 28528055 DOI: 10.1016/j.athoracsur.2016.11.084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 10/28/2016] [Accepted: 11/27/2016] [Indexed: 10/19/2022]
Abstract
Pseudoachalasia is known to be associated with malignancy involving the gastroesophageal junction and after esophageal operations. We present a case of pseudoachalasia secondary to an aneurysm of the descending thoracic aorta and describe successful operative management.
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Affiliation(s)
- Jorind Beqari
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Anthony Lembo
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jon Critchlow
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Allen Hamden
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Ribeiro MCB, Araújo ABD, Terra-Júnior JA, Crema E, Andreollo NA. LATE EVALUATION OF PATIENTS OPERATED FOR GASTROESOPHAGEAL REFLUX DISEASE BY NISSEN FUNDOPLICATION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2017; 29:131-134. [PMID: 27759771 PMCID: PMC5074659 DOI: 10.1590/0102-6720201600030001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/07/2016] [Indexed: 12/13/2022]
Abstract
Background: Surgical treatment of GERD by Nissen fundoplication is effective and safe,
providing good results in the control of the disease. However, some authors have
questioned the efficacy of this procedure and few studies on the long-term
outcomes are available in the literature, especially in Brazil. Aim: To evaluate patients operated for gastro-esophageal reflux disease, for at least
10 years, by Nissen fundoplication. Methods: Thirty-two patients were interviewed and underwent upper digestive endoscopy,
esophageal manometry, 24 h pH monitoring and barium esophagogram, before and after
Nissen fundoplication. Results: Most patients were asymptomatic, satisfied with the result of surgery (87.5%) 10
years after operation, due to better symptom control compared with preoperative
and, would do it again (84.38%). However, 62.5% were in use of some type of
anti-reflux drugs. The manometry revealed lower esophageal sphincter with a mean
pressure of 11.7 cm H2O and an average length of 2.85 cm. The average
DeMeester index in pH monitoring was 11.47. The endoscopy revealed that most
patients had a normal result (58.06%) or mild esophagitis (35.48%). Barium swallow
revealed mild esophageal dilatation in 25,80% and hiatal hernia in 12.9% of cases.
Conclusion: After at least a decade, most patients were satisfied with the operation,
asymptomatic or had milder symptoms of GERD, being better and with easier control,
compared to the preoperative period. Nevertheless, a considerable percentage still
employed anti-reflux medications.
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Affiliation(s)
- Maxwel Capsy Boga Ribeiro
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Amanda Bueno de Araújo
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Juverson Alves Terra-Júnior
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Eduardo Crema
- Clinics Hospital and Department of Surgery, Faculty of Medicine, Federal University of Triângulo Mineiro, Uberaba, Brazil
| | - Nelson Adami Andreollo
- Program in Sciences of Surgery, State University of Campinas, Unicamp, Campinas, SP, Brazil
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Losh JM, Sanchez B, Waxman K. Refractory pseudoachalasia secondary to laparoscopically placed adjustable gastric band successfully treated with Heller myotomy. Surg Obes Relat Dis 2017; 13:e4-e8. [DOI: 10.1016/j.soard.2016.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 10/06/2016] [Accepted: 10/08/2016] [Indexed: 10/20/2022]
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Akiyama J, Bertelé A, Brock C, Hvid-Jensen F, Ichiya T, Krarup AL, Majewski M, Rubio CA, Sarosiek J, Scarpignato C, Schmidt PT, Teich S, Triadafilopoulos G, Wallner G. Benign and precursor lesions in the esophagus. Ann N Y Acad Sci 2014; 1325:226-41. [DOI: 10.1111/nyas.12534] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Anna Bertelé
- Division of Gastroenterology & Digestive Endoscopy; Maggiore University Hospital; Parma Italy
| | - Christina Brock
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
| | - Frederik Hvid-Jensen
- Department of Surgical Gastroenterology; Aarhus University Hospital; Aarhus Denmark
| | - Tamaki Ichiya
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Anne Lund Krarup
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
| | - Marek Majewski
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
| | - Carlos A. Rubio
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Jerzy Sarosiek
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology; Clinical Pharmacology & Digestive Pathophysiology Unit; Department of Clinical & Experimental Medicine; University of Parma; Parma Italy
| | - Peter Thelin Schmidt
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Steven Teich
- Division of Pediatric Surgery; The Ohio State University College of Medicine; Columbus Ohio
| | | | - Grzegorz Wallner
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
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Saino G, Bona D, Nencioni M, Rubino B, Bonavina L. Laparoscopic diagnosis of pleural mesothelioma presenting with pseudoachalasia. World J Gastroenterol 2009; 15:3569-72. [PMID: 19630117 PMCID: PMC2715988 DOI: 10.3748/wjg.15.3569] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pseudoachalasia due to pleural mesothelioma is an extremely rare condition. A 70-year-old woman presented with progressive dysphagia for solid and liquids and a mild weight loss. A barium swallow study revealed an esophageal dilatation and a smoothly narrowed esophagogastric junction. An esophageal manometry showed absence of peristalsis. Endoscopy demonstrated an extrinsic stenosis of the distal esophagus with negative biopsies. A marked thickening of the distal esophagus and a right-sided pleural effusion were evident at computed tomography (CT) scan, but cytological examination of the thoracic fluid was negative. Endoscopic ultrasound showed the disappearance of the distal esophageal wall stratification and thickening of the esophageal wall. The patient underwent an explorative laparoscopy. Biopsies of the esophageal muscle were consistent with the diagnosis of epithelioid type pleural mesothelioma. An esophageal stent was placed for palliation of dysphagia. The patient died four months after the diagnosis. This is the first reported case of pleural mesothelioma diagnosed through laparoscopy.
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