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Kulkarni A, Ghoshal UC, Shirol VV, Elhence A, Fatima B, Agrahari AP, Misra A. True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs. Indian J Gastroenterol 2023; 42:549-557. [PMID: 37306890 DOI: 10.1007/s12664-023-01372-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/10/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as the use of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis. METHODS Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3 cm in length along 20 mmHg isobaric contour with a distal latency of less than 4.5 seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria. RESULTS Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions. CONCLUSION True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.
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Affiliation(s)
- Akshay Kulkarni
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India.
| | - Vivek V Shirol
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Bushra Fatima
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Anand Prakash Agrahari
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
| | - Asha Misra
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226 014, India
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2
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Kulkarni A, Elhence A, Ghoshal UC. Peristaltic Recovery After Peroral Endoscopic Myotomy for Achalasia: Dream or Reality? J Neurogastroenterol Motil 2022; 28:161. [PMID: 34980699 PMCID: PMC8748840 DOI: 10.5056/jnm21136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Akshay Kulkarni
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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3
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Vackova Z, Mares J, Krajciova J, Rabekova Z, Zdrhova L, Loudova P, Spicak J, Stirand P, Hucl T, Martinek J. Esophageal Motility Patterns After Peroral Endoscopic Myotomy in Patients With Achalasia. J Neurogastroenterol Motil 2021; 27:205-214. [PMID: 33462158 PMCID: PMC8026367 DOI: 10.5056/jnm20126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/28/2020] [Accepted: 09/20/2020] [Indexed: 01/16/2023] Open
Abstract
Background/Aims Several studies have reported partial recovery of peristalsis in patients with achalasia after myotomy. The aim of our study is to analyze esophageal motility patterns after peroral endoscopic myotomy (POEM) and to assess the potential predictors and clinical impact of peristaltic recovery. Methods We performed a retrospective analysis of prospectively collected data of consecutive patients with achalasia undergoing POEM at a tertiary center. High-resolution manometry (HRM) studies prior to and after POEM were reviewed and the Chicago classification was applied. Results A total of 237 patients were analyzed. The initial HRM diagnoses were achalasia type I, 42 (17.7%); type II, 173 (73.0%); and type III, 22 (9.3%). Before POEM, peristaltic fragments were present in 23 (9.7%) patients. After POEM the Chicago classification diagnoses were 112 absent contractility, 42 type I achalasia, 15 type II, 11 type III, 26 ineffective esophageal motility, 18 esophagogastric junction outflow obstruction, 10 fragmented peristalsis, and 3 distal esophageal spasm. Altogether 68 patients (28.7%) had signs of contractile activity, but the contractions newly appeared in 47 patients (47/214, 22.0%). Type II achalasia showed a trend for appearance of contractions (P = 0.097). Logistic regression analysis did not identify any predictors of peristaltic recovery. The post-POEM Eckardt score did not differ between patients with and without contractions nor did the parameters of timed barium esophagogram. Conclusions More than 20% of achalasia patients have signs of partial recovery of esophageal peristalsis after POEM. It occurs predominantly in type II achalasia but the clinical relevance seems to be negligible.
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Affiliation(s)
- Zuzana Vackova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Institute of Physiology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Mares
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jana Krajciova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Institute of Physiology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Rabekova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Institute of Physiology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lucie Zdrhova
- Department of Internal Medicine, University Hospital Plzen, Czech Republic
| | - Pavla Loudova
- Department of Gastroenterology, Hospital Kolin, Czech Republic; and 5Ostrava University, Faculty of Medicine, Ostrava, Czech Republic
| | - Julius Spicak
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Stirand
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Tomas Hucl
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Institute of Physiology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
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4
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Foisy H, Pioche M, Chabrun E, Ponchon T, Zerbib F, Rivory J, Mion F, Roman S. Role of Rapid Drink Challenge During Esophageal High-resolution Manometry in Predicting Outcome of Peroral Endoscopic Myotomy in Patients With Achalasia. J Neurogastroenterol Motil 2020; 26:204-214. [PMID: 32027787 PMCID: PMC7176508 DOI: 10.5056/jnm19135] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Peroral endoscopy myotomy (POEM) is effective to treat achalasia. We aim to determine POEM effect on esophageal function and search for predictive factors of response to POEM and co-occurrence of gastroesophageal reflux disease (GERD). Methods A total of 64 untreated achalasia patients who underwent high-resolution manometry (HRM) before and 3 months after POEM were retrospectively included. Response to treatment was defined as an Eckardt score < 3. Reflux symptoms and patient's satisfaction were evaluated. Data were compared using paired t test, Chi-square test or log rank test. Results The 2-year success rate in response to POEM was 90%. All responders reported being satisfied while only 33% of non-responders did (P < 0.001) and 64% of patients with reflux symptoms were satisfied versus 96% of those without (P = 0.009). On HRM, the integrated relaxation pressure and the contractile pattern changed significantly after POEM but were not predictive of response. Between pre and post POEM HRM, a decrease in maximal esophageal pressurization during rapid drink challenge (RDC) was associated with a better response rate than an increase of pressurization (91% vs 50%, P = 0.004). As evidenced by pH monitoring performed after POEM, GERD was pathological or borderline in 50% of patients (18/36) while only 19% (11/59) reported clinically significant reflux symptoms. On post POEM HRM, maximal esophageal pressurization during RDC was lower in patients with pathological or borderline GERD compared to those without (P = 0.054). Conclusions Esophageal HRM parameters changed significantly after POEM. Maximal esophageal pressurization during RDC may be useful to predict outcome.
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Affiliation(s)
- Hélène Foisy
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France
| | - Mathieu Pioche
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France
| | - Edouard Chabrun
- Université de Bordeaux, CHU de Bordeaux, Gastroenterology, Hôpital Haut Leveque, Pessac, France
| | - Thierry Ponchon
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France
| | - Frank Zerbib
- Université de Bordeaux, CHU de Bordeaux, Gastroenterology, Hôpital Haut Leveque, Pessac, France
| | - Jérôme Rivory
- Université de Lyon, Hospices Civils de Lyon, Gastroenterology, Hopital E Herriot, Lyon, France
| | - François Mion
- Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France.,Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hôpital E Herriot, Lyon, France
| | - Sabine Roman
- Université de Lyon, Lyon I University, Digestive Physiology, Lyon, France.,Université de Lyon, Inserm U1032, Labtau, Lyon, France.,Université de Lyon, Hospices Civils de Lyon, Digestive Physiology, Hôpital E Herriot, Lyon, France
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5
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Grobman ME, Hutcheson KD, Lever TE, Mann FA, Reinero CR. Mechanical dilation, botulinum toxin A injection, and surgical myotomy with fundoplication for treatment of lower esophageal sphincter achalasia-like syndrome in dogs. J Vet Intern Med 2019; 33:1423-1433. [PMID: 30968469 PMCID: PMC6524387 DOI: 10.1111/jvim.15476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/26/2019] [Indexed: 12/17/2022] Open
Abstract
Background Megaesophagus (ME) carries a poor long‐term prognosis in dogs. In people, lower esophageal sphincter (LES) achalasia is a rare cause of ME that may respond to targeted intervention. Dogs with lower esophageal sphincter achalasia‐like syndrome (LES‐AS) have been described recently, warranting investigation of analogous targeted treatment. Hypothesis/Objectives Evaluate response of dogs with LES‐AS to LES mechanical dilation and botulinum toxin A (BTA) injections, with or without surgical myotomy and fundoplication. We hypothesized that clinical and videofluoroscopic swallow study (VFSS) features of LES‐AS would improve after treatment targeting functional LES obstruction. Animals Fourteen client‐owned dogs with LES‐AS diagnosed by VFSS. Methods Retrospective study. Dogs diagnosed with LES‐AS underwent treatment between April 2015 and December 2017. Outcome measures included client perception of clinical severity, body weight (BW), body condition score (BCS), regurgitation frequency, and VFSS parameters (ME, esophageal motility, gastric filling). Dogs with positive responses were considered candidates for LES myotomy with fundoplication. Results By a median IQR of 21 (IQR, 14‐25) days after mechanical dilation and BTA, clients reported clinical improvement in 100% of dogs, BW increased 20.4% (IQR, 12.7%‐25%), pre‐ and post‐treatment BCS was 3 (IQR, 3‐4) and 5 (IQR, 4‐5), respectively, and frequency of regurgitation decreased by 80% (IQR, 50%‐85%). Duration of effect was 40 (IQR, 17‐53) days. Despite clinical improvement, ME and abnormal esophageal motility persisted in 14 dogs. Six dogs subsequently underwent myotomy and fundoplication and maintained improvement observed after mechanical dilation and BTA. Conclusions and Clinical Importance Dogs with LES‐AS experienced significant, temporary, clinical improvement after mechanical dilation and BTA. Preliminary results suggest myotomy with fundoplication provide lasting clinical benefit despite persistence of ME.
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Affiliation(s)
- M E Grobman
- Department of Veterinary Medicine and Surgery, University of Missouri College of Veterinary Medicine, Columbia, Missouri
| | - K D Hutcheson
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - T E Lever
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri Columbia School of Medicine Ringgold Standard Institution, Columbia, Missouri
| | - F A Mann
- Department of Veterinary Medicine and Surgery, University of Missouri Columbia College of Veterinary Medicine Ringgold Standard Institution, Columbia, Missouri
| | - C R Reinero
- Department of Veterinary Medicine and Surgery, University of Missouri, Columbia, Missouri
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Salvador R, Savarino E, Pesenti E, Spadotto L, Voltarel G, Capovilla G, Cavallin F, Nicoletti L, Valmasoni M, Ruol A, Merigliano S, Costantini M. Effects of laparoscopic myotomy on the esophageal motility pattern of esophageal achalasia as measured by high-resolution manometry. Surg Endosc 2016; 31:3510-3518. [DOI: 10.1007/s00464-016-5377-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 11/25/2016] [Indexed: 01/11/2023]
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7
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Roman S, Kahrilas PJ, Mion F, Nealis TB, Soper NJ, Poncet G, Nicodème F, Hungness E, Pandolfino JE. Partial recovery of peristalsis after myotomy for achalasia: more the rule than the exception. JAMA Surg 2013; 148:157-64. [PMID: 23426591 DOI: 10.1001/2013.jamasurg.38] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
IMPORTANCE Although successful treatment of achalasia depends on alleviating the obstruction at the esophagogastric junction, the postintervention contractile and pressurization pattern may also play a role in outcome. OBJECTIVE To determine whether myotomy that alleviates the esophagogastric junction outflow obstruction in achalasia might improve peristalsis. DESIGN Retrospective study from August 1, 2004, through January 30, 2012. SETTING Two tertiary care hospitals in Chicago and Lyon. PATIENTS We included 30 patients (18 male; mean age [range], 43 [17-78] years), of whom 8 had type 1 (26.6%), 17 had type 2 (56.7%), and 5 (16.7%) had type 3 achalasia according to the Chicago classification. INTERVENTIONS Esophageal high-resolution manometry before and after laparoscopic or endoscopic myotomy. MAIN OUTCOMES MEASURE The integrity of peristalsis, characterized as intact, weak contractions; frequent failed peristalsis; or premature contractions. RESULTS Although peristaltic fragments were evident only in patients with type 3 achalasia before treatment, intact, weak, or frequent failed peristalsis was encountered in 5 patients with type 1 (63%), 8 with type 2 (47%), and 4 with type 3 (80%) achalasia after myotomy. One patient with type 3 achalasia had distal esophageal spasm after treatment. In patients with a postmyotomy integrated relaxation pressure of less than 15 mm Hg, only 10 (40%) had persistent absent peristalsis. Panesophageal pressurization disappeared after myotomy in 16 of 19 patients. In the 5 patients with postmyotomy integrated relaxation pressure of more than 15 mm Hg, 4 had weak peristalsis and 1 had absent peristalsis. CONCLUSIONS AND RELEVANCE Reduction or normalization of the esophagogastric junction relaxation pressure achieved by myotomy in achalasia is associated with partial recovery of peristalsis in some patients, suggesting that the disease process progresses from the esophagogastric junction to the esophageal body. Whether the return of peristalsis is predictive of an improved therapeutic outcome requires further study.
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Affiliation(s)
- Sabine Roman
- Department of Digestive Physiology, Edouard Herriot Hospital, Pavillon H, 5 place d’Arsonval, 69437 Lyon, CEDEX 03, France.
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8
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Yu L, Li J, Wang T, Zhang Y, Krasna MJ. Functional analysis of long-term outcome after Heller's myotomy for achalasia. Dis Esophagus 2010; 23:277-83. [PMID: 20002701 DOI: 10.1111/j.1442-2050.2009.01031.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Treatment of achalasia aims at reducing the pressure of the lower esophageal sphincter (LES) and palliate symptoms. Our objective in this study was to investigate functional changes of the esophagus after Heller myotomy and evaluate their influence on postoperative gastroesophageal reflux and esophageal morphologic changes. Between 1980 and 2003, 216 patients with achalasia underwent Heller myotomy, associated with anterior partial fundoplication (Dor fundoplication). Preoperative and long-term outcome data were collected from these patients at our hospital. The objective was to analyze esophageal functional results after Heller myotomy in the long term. Results were classified as excellent, good, fair, or poor, according to Vantrappen and Hellemans' modified classification. One-year, 2-year, 5-year, 10-year, and 20-year postoperative follow-up information was available in 100% of all patients, 91.7%, 85.1%, 60%, 52.6%, and 45.9%, respectively. There were no perioperative deaths. One year after the surgery, all patients had a significant reduction in symptoms of dysphagia and regurgitation. Five years, 10 years, 15 years, and 20 years after surgery, there were 77.2% of patients (142 in 184), 68.1%, 57.1%, and 54.5%, respectively, who were satisfied (excellent to good) with surgery. No esophageal peristalsis was demonstrated in patients during follow-up. Contractile waves in the body of the esophagus were simultaneous. The difference in the distal esophageal amplitude, the LES relaxation rate, and LES pressures in the anterior wall and/ or two sides was significant (P < 0.05) when compared before and after operation. However, there was no significant difference in the LES length and LES pressure in the posterior side. The change of direction of the LES pressure and the relaxation of LES correlate with long-term outcomes. Postoperative gastroesophageal reflux rates, including nocturnal reflux, increased with time. The percentage of patients whose esophageal diameter became normal or remained mildly increased with time in the first 10 years after surgery changed significantly. Myotomy is an effective way to palliate symptoms in patients with achalasia. Adequate myotomy can lead to reduction of LES pressure in two or three directions, which may facilitate esophageal emptying by gravity. Surgical intervention does not lead to the return of esophageal peristalsis. Functional damage of LES in patients with achalasia is irreversible.
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Affiliation(s)
- L Yu
- Department of Thoracic Surgery, Beijing Tongren Hospital, Capital Medical University, Bijing, China.
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9
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Transient Lower Esophageal Sphincter Relaxation and Esophageal Motor Response. J Surg Res 2010; 159:714-9. [DOI: 10.1016/j.jss.2009.02.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 02/05/2009] [Accepted: 02/23/2009] [Indexed: 11/19/2022]
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10
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Bravi I, Nicita MT, Duca P, Grigolon A, Cantù P, Caparello C, Penagini R. A pneumatic dilation strategy in achalasia: prospective outcome and effects on oesophageal motor function in the long term. Aliment Pharmacol Ther 2010; 31:658-65. [PMID: 20003094 DOI: 10.1111/j.1365-2036.2009.04217.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Long-term follow-up studies of achalasia after pneumatic dilation, mostly retrospective, have shown variable results. AIM To examine the outcome of achalasia after pneumatic dilation using a prospective follow-up programme. METHODS One or two dilations (first dilation treatment) in 77 patients to achieve stable (>1 year) remission and patients followed up with yearly clinical and manometric assessments. Endoscopy, pH monitoring and barium swallow were also performed. RESULTS A total of 69 patients achieved stable remission and were followed up for 5.6 years (3-10.7) [median (IQ range)], whereas six patients underwent cardiomyotomy and two experienced a perforation. Twelve of the 69 patients relapsed after 2.6 years (1.7-5.1): nine of 12 underwent one to two further dilations. Six-year remission rate (by Kaplan-Meyer estimates) was 82% after first dilation treatment and 96% after all dilations. Continuous antisecretory treatment was clinically needed in 16%, oesophagitis present in 7% and reflux pathological in 28% of the patients. Beneficial effects of dilation on oesophageal motility and on diameter of the oesophageal body at barium swallow were maintained during follow-up. CONCLUSIONS A management strategy including sessions of pneumatic dilation until stable remission and a standardized follow-up is highly successful in the long term. Gastro-oesophageal reflux is clinically relevant in a minority of patients.
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Affiliation(s)
- I Bravi
- Cattedra di Gastroenterologia, Dipartimento di Scienze Mediche and Istituto di Biometria e Statistica Medica, Università degli Studi and Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena, Milan, Italy
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11
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Abstract
Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and confirmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients’ characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.
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12
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Fisichella PM, Raz D, Palazzo F, Niponmick I, Patti MG. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg 2009; 32:1974-9. [PMID: 18575930 DOI: 10.1007/s00268-008-9656-z] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Esophageal achalasia is characterized by the absence of esophageal peristalsis and by a dysfunctional lower esophageal sphincter (LES). Descriptions of clinical, radiological, and manometric findings in patients with achalasia usually have been based on small numbers of patients. This study was designed to determine in patients with untreated achalasia: (1) clinical presentation; (2) how often a diagnosis of gastroesophageal reflux disease (GERD) was erroneously made based on the presence of heartburn; (3) manometric profile; (4) relationship between chest pain and the manometric finding of vigorous achalasia. METHODS Between 1990 and 2004, a diagnosis of esophageal achalasia was established in 145 patients. None of them had been previously treated (no previous endoscopic or surgical treatment). We evaluated the demographic and clinical characteristics, as well as the results of the endoscopy, barium swallow, esophageal manometry, and ambulatory pH monitoring. We also compared the clinical and the manometric profile of patients with classic and patients with vigorous achalasia. RESULTS Most patients with untreated achalasia had dysphagia (94%). Regurgitation was present in 76% and heartburn in 52%. Chest pain (41%) and weight loss (35%) were less common. Acid-suppressing medications had been prescribed to 65 patients (45%) who complained of heartburn on the assumption that GERD was present. The LES was hypertensive in 43% of patients only. There was no significant difference in the prevalence, severity, and duration of chest pain in patients with classic and with vigorous achalasia. CONCLUSIONS These results show that in patients with untreated achalasia: (1) dysphagia was the most frequent complaint, but regurgitation and heartburn were frequently present; (2) a diagnosis of GERD based on the presence of heartburn was highly unreliable; (3) the LES was hypertensive in less than half of patients; and (4) the prevalence, severity, and duration of chest pain did not correlate with the manometric finding of vigorous achalasia.
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Affiliation(s)
- Piero M Fisichella
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
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13
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Tatum RP, Wong JA, Figueredo EJ, Martin V, Oelschlager BK. Return of esophageal function after treatment for achalasia as determined by impedance-manometry. J Gastrointest Surg 2007; 11:1403-9. [PMID: 17786525 DOI: 10.1007/s11605-007-0293-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Accepted: 07/31/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment for achalasia is aimed at the lower esophageal sphincter (LES), although little is known about the effect, if any, of these treatments on esophageal body function (peristalsis and clearance). We sought to measure the effect of various treatments using combined manometry (peristalsis) with Multichannel Intraluminal Impedance (MII) (esophageal clearance). METHODS We enrolled 56 patients with Achalasia referred to the University of Washington Swallowing Center between January 2003 and January 2006. Each was grouped according to prior treatment: 38 were untreated (untreated achalasia), 10 had undergone botox injection or balloon dilation (endoscopic treatment), and 16 a laparoscopic Heller myotomy. The preoperative studies for 8 of the myotomy patients were included in the untreated achalasia group. Each patient completed a dysphagia severity questionnaire (scale 0-10). Peristalsis was analyzed by manometry and esophageal clearance of liquid and viscous material by MII. RESULTS Mean dysphagia severity scores were significantly better in patients after Heller Myotomy than in either of the other groups (2.0 vs. 5.3 in the endoscopic group and 6.5 in untreated achalasia, p < 0.05). Peristaltic contractions were observed in 63% of patients in the Heller myotomy group, compared with 40% in the endoscopic group and 8% in untreated achalasia (p < 0.05 for both treatment groups vs. untreated achalasia). Liquid clearance rates were significantly better in both treatment groups: 28% in Heller myotomy and 16% in endoscopic treatment compared to only 5% in untreated achalasia (p < 0.05). Similarly, viscous clearance rates were 19% in Heller myotomy and 11% in endoscopic treatment, vs. 2% in untreated achalasia (p < 0.05). In the subset of patients who underwent manometry/MII both pre- and postoperatively, peristalsis was observed more frequently postoperatively than in preop studies (63% of patients exhibiting peristalsis vs. 12%), as was complete clearance of liquid (35% of swallows vs. 14%) and viscous boluses (22% of swallows vs. 14%). These differences were not significant, however. In the patients who had a myotomy the return of peristalsis correlates with effective esophageal clearance (liquid bolus: r = 0.46, p = 0.09 and viscous bolus: r = 0.63, p < 0.05). There is no correlation between peristalsis and bolus clearance in the endoscopic treatment group. CONCLUSIONS With treatment Achalasia patients exhibit some restoration in peristalsis as well as improved bolus clearance. After Heller Myotomy, the return of peristalsis correlates with esophageal clearance, which may partly explain its superior relief of dysphagia.
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Affiliation(s)
- Roger P Tatum
- Department of Surgery, University of Washington, VA Puget Sound HCS, 1660 S. Columbian Way, s-112-gs, Seattle, WA 98108, USA.
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