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DeSouza M. Surgical Options for End-Stage Achalasia. Curr Gastroenterol Rep 2023; 25:267-274. [PMID: 37646894 DOI: 10.1007/s11894-023-00889-2] [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] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW Achalasia is one of the most commonly described primary esophageal motility disorders worldwide, but there is significant controversy regarding ideal management of end-stage disease. This article reviews the definition of end-stage achalasia and summarizes past and present surgical treatment. RECENT FINDINGS Myotomy of the lower esophageal sphincter remains the mainstay of treatment of achalasia, even in advanced disease. Esophagectomy may have benefit as a primary treatment modality in end-stage achalasia with sigmoid esophagus, but international guidelines recommend consideration of laparoscopic or endoscopic approaches initially in most patients. Novel peroral esophageal plication techniques may provide alternative treatment options in patients with significant esophageal dilation that fail myotomy or esophagectomy. SUMMARY End-stage achalasia is characterized by progressive tortuosity and dilation of the esophagus as a failure of primary peristalsis. Up to 20% of patients with achalasia will progress to end-stage disease. In most cases, laparoscopic or endoscopic myotomy is recommended as initial approach to surgical management.
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Affiliation(s)
- Melissa DeSouza
- Foregut Surgery, Center for Advanced Surgery, 4805 NE Glisan Ave, OR, 97,213, Portland, Oregon, USA.
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2
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Abstract
Esophagectomy for achalasia is reserved for patients with end-stage disease for whom prior treatment has failed. Esophagectomy can be performed safely through a variety of techniques. Conduit options include stomach, colon, and small intestine. There are many potential complications following esophagectomy. Outcomes of esophagectomy for achalasia are good when performed in experienced surgical centers.
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Affiliation(s)
- John Waters
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Linda W Martin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
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Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical Outcomes After Esophagectomy in Patients with Achalasia: a NSQIP Matched Analysis With Non-Achalasia Esophagectomy Patients. J Gastrointest Surg 2021; 25:2455-2462. [PMID: 34131865 DOI: 10.1007/s11605-021-05056-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/24/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE The data on surgical outcomes of esophagectomy in patients with achalasia is limited. We sought to evaluate surgical outcomes in achalasia patients after an esophagectomy versus non-achalasia patients to elucidate if the outcomes are affected by the diagnosis. METHODS We conducted a retrospective review of the National Surgical Quality Improvement Program database (2010-2018). Patients who underwent an esophagectomy (open or laparoscopic approach) were included. Patients were divided into two groups, achalasia vs non-achalasia patients, and matched using propensity match analysis. RESULTS Of the 10,997 esophagectomy patients who met inclusion criteria, 213 (1.9%) patients had a diagnosis of achalasia. A total of 418 patients were included for the final analysis, with 209 patients in each group (achalasia vs non-achalasia). The overall median age was 57 years (IQR 47-65 years), and 48.6% were female. Most underwent an open (93.1%) vs laparoscopic (6.9%) esophagectomy. Overall complication rate was 40%. No difference was identified on overall complications, readmission, reoperation, or mortality between both groups. Postoperative sepsis was significantly higher in the achalasia group, and organ space SSI was higher in the non-achalasia group. Multivariable analysis showed that a diagnosis (achalasia or non-achalasia) was not predictive of reoperation or overall complications. CONCLUSION Esophagectomy outcomes are similar in patients with achalasia vs non-achalasia, and the diagnosis of achalasia does not independently increase the risk of reoperation and overall complications. Finally, regardless of diagnosis, the potential for morbidity following esophagectomy, should to be discussed with patients in the preoperative setting.
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Affiliation(s)
- Samuel Torres-Landa
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Trevor D Crafts
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Amy E Jones
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Elizabeth N Dewey
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Stephanie G Wood
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA.
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Felix VN, Murayama KM, Bonavina L, Park MI. Achalasia: what to do in the face of failures of Heller myotomy. Ann N Y Acad Sci 2020; 1481:236-246. [PMID: 32713020 DOI: 10.1111/nyas.14440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/07/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022]
Abstract
Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.
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Affiliation(s)
- Valter N Felix
- Nucleus of General and Specialized Surgery - São Paulo and Department of Gastroenterology - Surgical Division - São Paulo University, FMUSP, Sao Paulo, Brazil
| | - Kenric M Murayama
- Department of Surgery, John A. Burns School of Medicine, the University of Hawaii at Manoa, Honolulu, Hawaii
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, The University of Milan, San Donato Milanese, Italy
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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Pantanali CAR, Herbella FAM, Henry MA, Mattos Farah JF, Patti MG. Laparoscopic Heller Myotomy and Fundoplication in Patients with Chagas’ Disease Achalasia and Massively Dilated Esophagus. Am Surg 2020. [DOI: 10.1177/000313481307900133] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Laparoscopic Heller myotomy and fundoplication is considered today the treatment of choice for achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still controversial. This multicenter and retrospective study aims to evaluate the outcome of laparoscopic Heller myotomy in patients with a massively dilated esophagus. Eleven patients (mean age, 56 years; 6 men) with massively dilated esophagus (esophageal diameter greater than 10 cm) underwent a laparoscopic Heller myotomy and anterior fundoplication between 2000 and 2009 at three different institutions. Preoperative workup included upper endoscopy, esophagram, and esophageal manometry in all patients. Average follow-up was 31.5 months (range, 3 to 60 months). Two patients (18%) had severe dysphagia, four patients (36%) had mild and occasional dysphagia to solid food, and five patients (45%) were asymptomatic. All patients gained or kept body weight, except for the two patients with severe dysphagia. Of the two patients with severe dysphagia, one underwent esophageal dilatation and the other a laparoscopic esophagectomy. They are both doing well. Heller myotomy relieves dysphagia in the majority of patients even when the esophagus is massively dilated.
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Affiliation(s)
- Carlos A. R. Pantanali
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil; the
| | - Fernando A. M. Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, São Paulo, SP, Brazil; the
| | - Maria A. Henry
- Department of Surgery and Orthopedics, State University of São Paulo, Botucatu, SP, Brazil
| | - Jose Francisco Mattos Farah
- Department of Surgery, Hospital do Servidor Público Estadual de São Paulo Francisco Morato de Oliveira, São Paulo, SP, Brazil
| | - Marco G. Patti
- Department of Surgery, University of Chicago, Chicago, Illinois
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Abstract
Achalasia is a rare disease characterized by impaired lower esophageal sphincter relaxation loss and of peristalsis in the esophageal body. Endoscopic balloon dilation and laparoscopic surgical myotomy have been established as initial treatment modalities. Indications and outcomes of esophagectomy in the management of end-stage achalasia are less defined. A literature search was conducted to identify all reports on esophagectomy for end-stage achalasia between 1987 and 2017. MEDLINE, Embase, and Cochrane databases were consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy,” and “esophageal resection.” Seventeen articles met the inclusion criteria and 1422 patients were included in this narrative review. Most of the patients had previous multiple endoscopic and/or surgical treatments. Esophagectomy was performed through a transthoracic (74%) or a transhiatal (26%) approach. A thoracoscopic approach was used in a minority of patients and seemed to be safe and effective. In 95 per cent of patients, the stomach was used as an esophageal substitute. The mean postoperative morbidity rate was 27.1 per cent and the mortality rate 2.1 per cent. Symptom resolution was reported in 75 to 100 per cent of patients over a mean follow-up of 43 months. Only five series including 195 patients assessed the long-term follow-up (>5 years) after reconstruction with gastric or colon conduits, and the results seem similar. Esophagectomy for end-stage achalasia is safe and effective in tertiary referral centers. A thoracoscopic approach is a feasible and safe alternative to thoracotomy and may replace the transhiatal route in the future.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
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8
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Varshney VK, Soni SC, Kumari M, Garg PK, Puranik A. Thoracoscopic oesophagectomy for end-stage achalasia. J Minim Access Surg 2018; 14:253-255. [PMID: 29319022 PMCID: PMC6001294 DOI: 10.4103/jmas.jmas_222_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Achalasia cardia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of the lower oesophageal sphincter. The management is predominantly palliative with focus on addressing the sphincter that involves either pneumatic dilatation or Heller myotomy which relieves dysphagia in the majority of the cases. End-stage achalasia (ESA) is characterised by failed myotomy, massively dilated and tortuous oesophagus with nutritional deterioration due to progressive dysphagia and vomiting. In these subgroups of patients, oesophagectomy may be the last resort. While oesophagectomy has been described for ESA before, thoracoscopic oesophagectomy has not been reported previously. Hereby, we report our experience of performing minimally invasive oesophagectomy (thoracoscopic) with the gastric pull-up.
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Affiliation(s)
- Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Subhash Chandra Soni
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Manju Kumari
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Kumar Garg
- Department of Diagnostic and Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ashok Puranik
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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9
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Aiolfi A, Asti E, Bonitta G, Bonavina L. Esophagectomy for End-Stage Achalasia: Systematic Review and Meta-analysis. World J Surg 2017; 42:1469-1476. [DOI: 10.1007/s00268-017-4298-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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10
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Felix VN. Esophagectomy for end-stage achalasia. Ann N Y Acad Sci 2016; 1381:92-97. [DOI: 10.1111/nyas.13142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 05/16/2016] [Accepted: 05/23/2016] [Indexed: 11/28/2022]
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Abstract
Achalasia is a disease for which treatments are palliative in nature. Success of therapy is judged by a number of metrics, the most important being relief of symptoms, such as dysphagia and regurgitation. Patients often compensate for symptoms though a variety of dietary and lifestyle modifications, making symptomatic assessment of therapeutic outcome unreliable. Given this fact, and the progressive nature of the condition if left inadequately treated, patients not infrequently present with the disabling manifestations of end-stage disease for which esophagectomy is the best option. In appropriately selected patients, and when performed in experienced centers, esophagectomy with foregut reconstruction can be undertaken successfully with acceptable rates of morbidity and mortality, as well as a good long-term symptomatic outcome, in cases of end-stage achalasia.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box Surgery, Rochester, NY, 14642, USA,
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12
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Molena D, Mungo B, Stem M, Feinberg RL, Lidor AO. Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg 2014; 18:310-7. [PMID: 23963868 DOI: 10.1007/s11605-013-2318-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 08/06/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND While the outcomes after Heller myotomy have been extensively reported, little is known about patients with esophageal achalasia who are treated with esophagectomy. METHODS This was a retrospective analysis using the Nationwide Inpatient Sample over an 11-year period (2000-2010). Patients admitted with a primary diagnosis of achalasia who underwent esophagectomy (group 1) were compared to patients with esophageal cancer who underwent esophagectomy (group 2) during the same time period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, postoperative complications, and total hospital charges. A propensity-matched analysis was conducted comparing the same outcomes between group 1 and well-matched controls in group 2. RESULTS Nine hundred sixty-three patients with achalasia and 18,003 patients with esophageal cancer underwent esophagectomy. The propensity matched analysis showed a trend toward a higher mortality in group 2 (7.8 vs. 2.9 %, p = 0.08). Postoperative length of stay and complications were similar in both groups. Total hospital charges were higher for the achalasia group ($115,087 vs. $99, 654.2, p = 0.006). CONCLUSION This is the largest study to date examining outcomes after esophagectomy in patients with achalasia. Based on our findings, esophagectomy can be considered a safe option, and surgeons should not be hindered by a perceived notion of prohibitive operative risk in this patient population.
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Affiliation(s)
- Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University, 600 N Wolfe Street, Blalock 240, Baltimore, MD, 21287, USA,
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13
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Katada N, Sakuramoto S, Yamashita K, Shibata T, Moriya H, Kikuchi S, Watanabe M. Recent trends in the management of achalasia. Ann Thorac Cardiovasc Surg 2013; 18:420-8. [PMID: 23099422 DOI: 10.5761/atcs.ra.12.01949] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Radical treatment for achalasia is currently unavailable. At present, most palliative procedures are designed improve the passage of food through the gastroesophageal junction and thereby alleviate symptoms. Drug therapy is of limited, transient effectiveness. Pneumatic dilation (PD) is considered superior to endoscopic botulinum toxin injection (EBTI). The mainstay of surgical treatment for achalasia is laparoscopic Heller myotomy (LHM) with fundoplication, currently considered superior to PD. Per oral endoscopic myotomy (POEM), a "state-of-the-art" procedure for minimally invasive surgery, holds great promise for the future management of achalasia. Definitive conclusions regarding the benefits and risks of currently available treatments for achalasia must await the accumulation of evidence from well-designed clinical trials.
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Affiliation(s)
- Natsuya Katada
- Department of Surgery, School of Medicine, Kitasato University, Sagamihara, Kanagawa, Japan.
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14
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Molena D, Yang SC. Surgical management of end-stage achalasia. Semin Thorac Cardiovasc Surg 2012; 24:19-26. [PMID: 22643658 DOI: 10.1053/j.semtcvs.2012.01.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2012] [Indexed: 02/07/2023]
Abstract
Esophageal achalasia is a chronic and progressive motility disorder that leads to massive esophageal dilation when left untreated. Treatment for achalasia is palliative and aimed to relieve the outflow obstruction at the level of the lower esophageal sphincter, yet protecting the esophageal mucosa from refluxing gastric acids. The best way to accomplish this goal is through an esophageal myotomy and partial fundoplication, with a success rate >90%. Progression of disease, treatment failure, and complications from gastroesophageal reflux disease cause progressive deterioration of the esophageal function to an end stage in about 5% of patients. The only chance to improve symptoms in this small group of patients is through an esophageal resection. This article will review the indications for esophagectomy in end-stage achalasia, present the different types of surgical approach and possibilities for reconstruction of the alimentary tract, and summarize the short-term and long-term postoperative results.
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Affiliation(s)
- Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA
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15
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Abstract
Despite symptom improvement offered to achalasia patients by either pneumatic dilation or surgical myotomy, 10% to 15% of those so treated will present progressive deterioration of their esophageal function and up to 5% may eventually require an esophagectomy. The natural evolution of achalasia to its end stage as well as the timing of esophagectomy in these patients form the basis of this review. The optimal reconstruction for the decompensated resected esophagus will also be explored: gastric interposition, colon interposition, and jejunal interposition all have their respective advantages and disadvantages. Their use is examined in the exclusive context of resection for achalasia.
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Affiliation(s)
- A Duranceau
- Department of Surgery, Université de Montréal, Division of Thoracic Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
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Howard JM, Ryan L, Lim KT, Reynolds JV. Oesophagectomy in the management of end-stage achalasia - case reports and a review of the literature. Int J Surg 2011; 9:204-8. [PMID: 21111851 DOI: 10.1016/j.ijsu.2010.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2010] [Revised: 11/04/2010] [Accepted: 11/17/2010] [Indexed: 02/07/2023]
Abstract
Achalasia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of a hypertensive lower oesophageal sphincter. Treatment intent targets the sphincter, and either Heller's myotomy or pneumatic dilatation successfully relieves dysphagia in the majority of cases. End-stage achalasia, typified by a massively dilated and tortuous oesophagus, may occur in patients previously treated but where further dilatation or myotomy fails to relieve dysphagia or prevent nutritional deterioration, and oesophagectomy may be the only option. We describe two patients with end-stage achalasia and nutritional failure despite exhaustive conventional therapy including pneumatic dilatation and surgical myotomy. Both patients were successfully managed with transhiatal oesophagectomy and cervical gastro-esophageal anastomosis, with excellent symptomatic control and improved quality of life. These cases are discussed and the literature reviewed.
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Affiliation(s)
- Julia M Howard
- Department of Surgery, St. James's Hospital, Dublin 8, Ireland.
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Braghetto I, Korn O, Cardemil G, Coddou E, Valladares H, Henriquez A. Inversed Y cardioplasty plus a truncal vagotomy-antrectomy and a Roux-en-Y gastrojejunostomy performed in patients with stricture of the esophagogastric junction after a failed cardiomyotomy or endoscopic procedure in patients with achalasia of the esophagus. Dis Esophagus 2010; 23:208-15. [PMID: 19903194 DOI: 10.1111/j.1442-2050.2009.01021.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
Laparoscopic anterior cardiomyotomy in addition to anterior Dor's fundoplication is the procedure of choice for achalasia of the esophagus with approximately 95% success rate. Redo cardiomyotomy is complicated and associated with rerecurrence of dysphagia. Twelve patients with failed redo myotomy were clinically evaluated with radiology, endoscopy, and manometry in whom achalasia type III or IV was confirmed. We propose as treatment for these selected cases an inversed Y cardioplasty + truncal vagotomy, a partial distal gastrectomy and Roux-en-Y gastrojejunostomy in order to facilitate esophageal emptying and avoid the appearance of postoperative gastroesophageal reflux as a side effect of this procedure. One patient was reoperated on in order to enlarge the cardioplasty. Disappearance of dysphagia was confirmed in all patients. Three patients presented reflux symptoms and were treated with 20 mg of Omeprazole 20 twice/day. No food retention, erosive esophagitis, or Barrett's esophagus were observed. The mean resting pressure decreased from 24.9 +/- 8.5 mm Hg to 7.5 +/- 2.5 mm Hg (P = 0.0001). Furthermore, esophageal diameter decreased significantly after a 5-year follow-up. This procedure could be an option for treating patients in which repeated Heller operations have failed.
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Affiliation(s)
- I Braghetto
- Department of Surgery, University of Chile, Santiago, Chile.
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18
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Schuchert MJ, Luketich JD, Landreneau RJ, Kilic A, Wang Y, Alvelo-Rivera M, Christie NA, Gilbert S, Pennathur A. Minimally invasive surgical treatment of sigmoidal esophagus in achalasia. J Gastrointest Surg 2009; 13:1029-35; discussion 1035-6. [PMID: 19326178 DOI: 10.1007/s11605-009-0843-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Accepted: 02/18/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients. METHODS We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25-83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure. RESULTS The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant. CONCLUSIONS MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients.
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Affiliation(s)
- Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Heart, Lung and Esophageal Surgery Institute, UPMC Health System, Shadyside Medical Building, Suite 715, 5200 Centre Avenue, Pittsburgh, PA 15232, USA.
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20
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Abstract
Achalasia is the best understood and most readily treatable esophageal motility disorder. It serves as a prototype for disorders of the enteric nervous system with degeneration of the myenteric neurons that innervate the lower esophageal sphincter (LES) and esophageal body. Investigations into the pathogenesis have highlighted the importance of nitric oxide and the possible role of an autoimmune response to a viral insult in genetically susceptible individuals. Advances in diagnostic testing have delineated manometric variants of achalasia that have implications for management. Treatment studies have demonstrated the limited efficacy of botulinum toxin as well as less than ideal, long-term effectiveness of both pneumatic dilation and Heller myotomy. This article incorporates these recent developments into the current understanding of achalasia.
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Affiliation(s)
- Natasha Walzer
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 676 North Saint Clair Street, Suite 1400, Chicago, IL 60611-3008, USA
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21
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Laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus following failed cardiomyotomy: experience of 11 patients. Dig Dis Sci 2008; 53:1513-8. [PMID: 17934854 DOI: 10.1007/s10620-007-0050-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Accepted: 09/26/2007] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Laparoscopic myotomy is a widely used procedure and is now considered to be the treatment of choice for achalasia. Esophagectomy for achalasia is usually performed only for megaesophagus. We present our experiences with laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus due to failed Heller's myotomy. MATERIALS AND METHODS We managed a total of 11 patients with megaesophagus in our institute from 1993 to 2007. Work-up included investigations included endoscopy, barium swallow, and manometry. Laparoscopic transhiatal esophagectomy with gastric pull through was successfully performed for all cases. RESULTS The mean operating time was 317.5 min, and the mean blood requirement was 525 ml. The mean duration between the first and second procedures was 13 months. Our overall failure rate for primary surgery (myotomy) was 3.1% and overall symptomatic improvement was achieved in 82% of patients. There were no conversions. DISCUSSION About 10% of postmyotomy patients will have recurrence, and 5% of them need reoperation. Laparoscopic esophagectomy for sigmoid esophagus is a formidable operation due to adhesions/fibrosis at the hiatal area. Dissection of the S-shaped esophagus in the thorax is quite tedious and an accurate knowledge of the shape and location of the megaesophagus preoperatively is vital. If performed in specialized centers, laparoscopic excision is safe and effective, utilizing all the benefits of minimal access.
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Katada N, Sakuramoto S, Kobayashi N, Futawatari N, Kuroyama S, Kikuchi S, Watanabe M. Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia. Am J Surg 2006; 192:1-8. [PMID: 16769266 DOI: 10.1016/j.amjsurg.2006.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2005] [Revised: 01/15/2006] [Accepted: 01/15/2006] [Indexed: 12/29/2022]
Abstract
BACKGROUND A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). METHODS LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. RESULTS The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 +/- 1.2 (mean +/- SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). CONCLUSIONS LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia.
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Affiliation(s)
- Natsuya Katada
- Department of Surgery, School of Medicine, Kitasato University 2-1-1, Asamizodai, Sagamihara, Kanagawa 228-8520, Japan.
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Heitmiller RF. Invited commentary. Ann Thorac Surg 2006; 81:2049. [PMID: 16731128 DOI: 10.1016/j.athoracsur.2006.01.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 01/24/2006] [Accepted: 01/30/2006] [Indexed: 11/29/2022]
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Campo SMA, Balsamo G, Zullo A, Hassan C, Morini S. Management of idiopathic achalasia: drugs, balloon or knife? Expert Opin Ther Pat 2005. [DOI: 10.1517/13543776.14.3.367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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25
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Caporale A, Cosenza UM, Galati G, Fiori E, Benvenuto E, Giuliani A. Oesophagocardioplasty for residual dysphagia following multiple pneumatic dilatations for achalasia. Br J Surg 2004; 91:995-6. [PMID: 15286960 DOI: 10.1002/bjs.4555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A novel approach to a difficult problem
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Affiliation(s)
- A Caporale
- Department of Surgery Pietro Valdoni, University La Sapienza, viale del Policlinico 155, 00161 Rome, Italy.
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Vela MF, Richter JE, Wachsberger D, Connor J, Rice TW. Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol 2004; 99:1029-36. [PMID: 15180721 DOI: 10.1111/j.1572-0241.2004.30199.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The purpose of this study is to describe the results and complexity of treatment for achalasia patients presenting to a single esophagologist at a tertiary referral center and to make treatment recommendations based on this experience. METHODS Retrospective chart review of achalasia patients treated between 1994 and 2002. Symptoms, manometric and timed barium esophagram results, and treatments/outcome at CCF determined. RESULTS 232 patients (51% male, mean age = 53) were evaluated. Untreated patients (n = 184): Pneumatic dilatation (PD) used in 111 patients. Symptoms and barium emptying improved in 86% and 54%, respectively. Nineteen (17%) patients required subsequent Heller myotomy (HM). Perforation rate: 3/111 (2.7%) patients. 16% required proton-pump inhibitor (PPI) for GERD. HM was used in 72 patients (81% laparoscopic). Symptoms and barium emptying improved in 89% and 44%, respectively. PPI required in 53%. Botulinum toxin (Botox) was used in 39 older patients (mean age = 71); symptom improvement lasted for a mean 6.2 months, with frequent need for repeated injection (mean: 1.7, range: 1-7). About 43% required additional treatment with a different modality. Esophagectomy was done in three patients. Patients with prior surgery (n = 48): PD (n = 10) achieved symptom and barium emptying improvement in 67% and 11%, comparable to redo HM (n = 21) with 57% symptom improvement and 38% improved emptying. Esophagectomy required in eight patients. CONCLUSIONS Successful management of achalasia can be complex and may require more than one treatment modality. PD and HM are presently the best treatments for untreated achalasia with similar efficacy but greater PPI use after surgery. Both are less successful after prior HM.
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Affiliation(s)
- Marcelo F Vela
- Center for Swallowing and Esophageal Disorders, Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Gockel I, Kneist W, Eckardt VF, Oberholzer K, Junginger T. Subtotal esophageal resection in motility disorders of the esophagus. Dig Dis 2004; 22:396-401. [PMID: 15812166 DOI: 10.1159/000083605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Esophagectomy for motility disorders is performed infrequently. It is indicated after failed medical therapy, pneumatic dilation, non-resecting surgical and redo procedures. Patient selection in this group is challenging and the operative risk has to be weighted carefully against the poor quality of life with persistent or recurrent dysphagia. PATIENTS AND METHODS Between September 1985 and April 2004, subtotal esophageal resections for advanced esophageal motility disorders of the esophagus not responding to previous therapy were carried out in 8 patients (6 females, 2 males). The median age of these patients was 59.5 (43-78) years. Six patients had a megaesophagus secondary to achalasia; 1 patient had a non-specific esophageal motility disorder with a stenosis of the distal esophagus, and a further patient displayed a recurrent huge epiphrenic diverticulum, which occurred in the context of a collagen disease. A transhiatal esophageal resection was performed in 6, a transthoracic procedure in 2 patients. RESULTS Outcome assessment was done after a follow-up of 43.5 (3-92) months in median. The resection and reconstruction of the esophagus in advanced and decompensated esophageal motility disorders led to a marked functional improvement with disappearance of dysphagia. Despite previous therapeutic failures, alimentation could be restored in all patients. CONCLUSION Favourable long-term results with significant improvement of symptoms can be achieved by esophageal resection even if endoscopic therapy or non-resecting surgical measures are unsuccessful. Transhiatal esophagectomy with gastric pull-up should be the preferred procedure and can be performed with low morbidity.
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Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg University, Mainz, Germany.
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Batista Neto J, Fontan AJ, Nepomuceno MDC, Lourenço LG, Ribeiro LT, Ramos CP. Esofagectomia trans-hiatal no tratamento do megaesôfago chagásico avançado. Rev Col Bras Cir 2003. [DOI: 10.1590/s0100-69912003000300011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar os resultados da esofagectomia trans-hiatal no tratamento do megaesôfago chagásico avançado. MÉTODO: Foram estudados retrospectivamente 28 pacientes portadores de megaesôfago chagásico avançado (MCA), graus III e IV, segundo a classificação radiológica de Rezende (adotada pela Organização Mundial de Saúde), e que foram submetidos à esofagectomia subtotal trans-hiatal no Serviço de Clínica Cirúrgica do Hospital Universitário Prof. Alberto Antunes (HUPAA) da Universidade Federal de Alagoas, entre 1982 e 2000. Foram analisadas, as seguintes variáveis: A) Queixas clínicas pré-operatórias versus as pós-operatórias (disfagia, regurgitação, pirose, diarréia, dumping, plenitude pós-prandial, pneumonia e o estado ponderal). B) avaliação radiológica pós-operatória da boca anastomótica esofagogástrica cervical e do estômago transposto. C) avaliação endoscópica pós-operatória do coto esofágico e da boca anastomótica. RESULTADOS: O seguimento variou de 4 a 192 meses, média de 58,18 meses. Dezesseis pacientes eram do sexo feminino e 12 masculinos. Idade mínima de 16 e máxima de 67 anos, média de 36,5 anos. Não houve mortalidade nesta série. Houve resolução plena da disfagia na maioria dos pacientes (20/28 - 71,4%), um (3,6%) referiu disfagia leve que não necessitou tratamento e 7/28 (25%) necessitaram de uma ou mais sessões de dilatação. Nenhum necessitou de dilatação permanente. A pirose foi o sintoma mais importante no seguimento tardio (35,7%), seguida da regurgitação (25%), diarréia (14,3%), plenitude pós-prandial (10,7%) e dumping (3,6%). Houve ganho ponderal em 87,5% dos pacientes avaliados. A esofagite no coto esofágico foi o achado endoscópico mais significativo (46,4%). O esôfago de Barrett no coto remanescente foi encontrada em 10,7% dos casos. A maioria dos achados radiológicos foi normal, embora três doentes (10,7%) tenham apresentado estase gástrica. CONCLUSÃO: A esofagectomia trans-hiatal mostrou-se eficaz para o tratamento da disfagia no megaesôfago chagásico avançado, embora com morbidade elevada, porém com mortalidade nula.
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Esophagus. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kostic SV, Rice TW, Baker ME, Decamp MM, Murthy SC, Rybicki LA, Blackstone EH, Richter JE. Timed barium esophagogram: A simple physiologic assessment for achalasia. J Thorac Cardiovasc Surg 2000; 120:935-43. [PMID: 11044320 DOI: 10.1067/mtc.2000.110463] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Success of achalasia therapy is difficult to determine because repeated physiologic study is impractical and symptoms are subjective. Timed barium esophagography directly measures esophageal emptying and is simple to perform. This study (1) evaluates the assessment of myotomy by timed barium esophagography and (2) compares it with premyotomy and postmyotomy symptoms. METHODS Fifty patients ingested 250 mL low-density barium and had upright films at 1, 2, and 5 minutes premyotomy. Forty-five underwent repeat timed barium esophagography 8 weeks (median) postmyotomy. Premyotomy and postmyotomy height and width of the barium column were compared and related to symptoms. RESULTS At 1, 2, and 5 minutes premyotomy, median barium column height was 19, 17, and 15 cm, and width was 5.2, 4.8, and 4.5 cm, respectively. Surgery reduced these to 7.0, 5.0, and 1.0 cm and to 3.5, 3.0, and 1.0 cm, respectively (P <.001). Postmyotomy complete esophageal emptying was seen in 29%, 36%, and 49% at 1, 2, and 5 minutes. Postmyotomy height was unrelated (r approximately 0.2) to premyotomy height but was directly related to premyotomy width (r = 0.3-0.5; P <.05); postmyotomy width was directly related to premyotomy width (r approximately 0.6; P <.001). Premyotomy dysphagia was more severe when little change in width occurred from 1 to 5 minutes (r = 0.26, P =.07). Premyotomy regurgitation was more severe the higher the barium column (r approximately 0.4, P <.007). Surgery relieved symptoms in the majority of patients (grade 2-5 dysphagia from 72% to 4%, grade 2-5 regurgitation from 79% to 4%). Postmyotomy symptoms were unrelated to the timed barium esophagogram. CONCLUSIONS (1) The timed barium esophagogram gives objective confirmation of successful myotomy. (2) Symptoms are unreliable in assessing esophageal emptying.
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Affiliation(s)
- S V Kostic
- Center for Swallowing and Esophageal Disorders, Departments of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Prakash C, Clouse RE. Esophageal motor disorders. Curr Opin Gastroenterol 2000; 16:360-8. [PMID: 17031102 DOI: 10.1097/00001574-200007000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Motor dysfunction is responsible for symptomatic illnesses both in the proximal skeletal muscle region and in the distal smooth muscle esophagus. Practical methods for diagnosing and treating oropharyngeal dysphagia continue to reach consensus. Achalasia, the most significant of the distal motor disorders, is of investigative interest because of the expanded armamentarium of treatment options. Minimally invasive surgical methods have taken an important foothold as a primary treatment of this disorder. Appreciation is growing for sensory dysfunction that accompanies distal motor disorders. Such dysfunction may help explain the observed discrepancies between symptoms and measurable motility abnormality.
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Affiliation(s)
- C Prakash
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Abstract
This article reviews current trends in management of esophageal achalasia, highlighting short-term outcome and cost comparisons of three treatments: botulinum toxin injection, pneumatic dilation, and laparoscopic myotomy. The quality of life resulting from these palliative treatments is also discussed, as are long-term outcomes.
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Affiliation(s)
- B T Massey
- Dysphagia Institute, Medical College of Wisconsin, Milwaukee 53266, USA.
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