1
|
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.
Collapse
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
| |
Collapse
|
2
|
Slim N, Williamson JM. Achalasia: investigation and management. Br J Hosp Med (Lond) 2023; 84:1-9. [PMID: 36708337 DOI: 10.12968/hmed.2022.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Achalasia, characterised by the absence of peristalsis and failure of relaxation of the lower oesophageal sphincter, is an uncommon degenerative condition that results in dysphagia. If left untreated it can lead to aspiration, oesophageal perforation, oesophagitis and malnutrition. It has a range of immune, allergic, viral and genetic aetiological causes. Successful diagnosis relies on the use of oesophagogastroduodenoscopy, barium swallow and oesophageal manometry to characterise the severity of the disease and to rule out underlying malignancy. Although no treatment can reverse the degenerative process, therapeutic strategies including lifestyle modification, medication, endoscopic and operative intervention can help to reduce symptoms. This article reviews the latest methods used to investigate and manage achalasia.
Collapse
Affiliation(s)
- Naim Slim
- Department of General Surgery, The Great Western Hospital, Swindon, UK
| | | |
Collapse
|
3
|
Patti MG, Schlottmann F, Herbella FAM. Once an achalasia patient always an achalasia patient: evaluation and treatment of recurrent symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00009-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
|
4
|
Dysphagia and other esophageal symptoms. Dysphagia 2023. [DOI: 10.1016/b978-0-323-99865-9.00002-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
|
5
|
Arcerito M, Jamal MM, Perez MG, Kaur H, Sundahl A, Moon JT. Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication. JSLS 2022; 26:JSLS.2022.00027. [PMID: 35967962 PMCID: PMC9355798 DOI: 10.4293/jsls.2022.00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort. Methods and Procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 – 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 – 480). Results: Median operative time was 144 minutes (90 – 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 – 312). Median follow up was 157 months (6 – 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation. Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.
Collapse
Affiliation(s)
- Massimo Arcerito
- Division of Surgical Oncology and Minimally Invasive Surgery Riverside Medical Clinic Inc. Department of Surgery/Corona Regional Medical Center, Department of Surgery/Riverside Community Hospital, Temescal Valley, California
| | - M Mazen Jamal
- Oceana Gastroenterology Associates, Corona, California
| | - Martin G Perez
- Division of Surgical Oncology and Minimally Invasive Surgery, Riverside Medical Clinic Inc, Department of Surgery / Corona Regional Medical Center, Department of Surgery / Riverside Community Hospital, Riverside, California
| | - Harpreet Kaur
- Hemet Global Medical Center - KPC Health, Hemet, California
| | - Andrew Sundahl
- Department of Surgery / Riverside Community Hospital, Riverside, California
| | - John T Moon
- Department of General Surgery and Minimally Invasive Surgery, University of Maryland Shore Medical Center at Easton, Easton, Maryland
| |
Collapse
|
6
|
Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms. World J Surg 2022; 46:1561-1566. [PMID: 35166877 DOI: 10.1007/s00268-022-06466-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime. METHODS A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia. RESULTS The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity. CONCLUSIONS The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.
Collapse
|
7
|
Fukui T, Okubo T, Tanimoto N, Okuma H, Shiina Y, Kohama M, Yamada J, Funada Y, Ikura Y. Malignant pleural mesothelioma in a patient with pneumothorax: A cumbersome subtype both clinically and pathologically. Thorac Cancer 2021; 12:974-977. [PMID: 33533198 PMCID: PMC7952799 DOI: 10.1111/1759-7714.13877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 11/30/2022] Open
Abstract
Here, we report a case of malignant pleural mesothelioma (MPM) that was very difficult to diagnose. A 62‐year‐old woman with a surgical history of recurrent bilateral pneumothorax was admitted to our hospital with severe dysphagia. Computed tomography (CT) detected stenosis in the lower esophagus. Immunohistochemical examination of a biopsy sample from the stenotic region was suggestive of MPM. Chemotherapy was initiated, but the patient soon weakened and died. Autopsy revealed atypical cells, identical to those seen in the biopsy sample which had spread into the stenotic esophagus and entire thoracic cavity. Although neither pleural thickening/nodules nor asbestos bodies were observed, we finally diagnosed the tumor as a biphasic‐type MPM. We re‐examined previous surgical specimens of pneumothorax and acknowledged foci of bland mesothelial cell proliferation which had the same pathological findings as tumor cells at autopsy. The lack of asbestos exposure and pleural thickening, an initial manifestation of pneumothorax, and faint cytological atypia prevented an early diagnosis. In cases of recurrent pneumothorax in elderly patients, MPM should be included in the differential diagnosis.
Collapse
Affiliation(s)
- Takafumi Fukui
- Department of Respiratory Medicine, Takatsuki General Hospital, Takatsuki, Japan
| | - Takako Okubo
- Department of Pathology, Takatsuki General Hospital, Takatsuki, Japan
| | - Naoki Tanimoto
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki, Japan
| | - Hiromichi Okuma
- Department of Thoracic Surgery, Takatsuki General Hospital, Takatsuki, Japan
| | - Yoshitaka Shiina
- Department of Thoracic Surgery, Takatsuki General Hospital, Takatsuki, Japan
| | - Mizuki Kohama
- Department of Respiratory Medicine, Takatsuki General Hospital, Takatsuki, Japan
| | - Jun Yamada
- Department of Respiratory Medicine, Takatsuki General Hospital, Takatsuki, Japan
| | - Yasuhiro Funada
- Department of Respiratory Medicine, Takatsuki General Hospital, Takatsuki, Japan
| | - Yoshihiro Ikura
- Department of Pathology, Takatsuki General Hospital, Takatsuki, Japan
| |
Collapse
|
8
|
Nurczyk K, Patti MG. Surgical management of achalasia. Ann Gastroenterol Surg 2020; 4:343-351. [PMID: 32724877 PMCID: PMC7382425 DOI: 10.1002/ags3.12344] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The cause of the disease is unknown. The goal of treatment is to eliminate the functional outflow obstruction at the level of the gastroesophageal junction, therefore allowing emptying of the esophagus into the stomach. They include the laparoscopic Heller myotomy with partial fundoplication, pneumatic dilatation, and peroral endoscopic myotomy. Esophagectomy is considered as a last resort for patients who have failed prior therapeutic attempts. In this evidence and experience-based review, we will illustrate the technique and results of the surgical treatment of esophageal achalasia and compare it to the other available treatment modalities.
Collapse
Affiliation(s)
- Kamil Nurczyk
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- 2nd Department of General and Gastrointestinal Surgery, and Surgical Oncology of the Alimentary TractMedical University of LublinLublinPoland
| | - Marco G. Patti
- Department of SurgeryUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
| |
Collapse
|
9
|
Schizas D, Theochari NA, Katsaros I, Mylonas KS, Triantafyllou T, Michalinos A, Kamberoglou D, Tsekrekos A, Rouvelas I. Pseudoachalasia: a systematic review of the literature. Esophagus 2020; 17:216-222. [PMID: 31989338 DOI: 10.1007/s10388-020-00720-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 02/03/2023]
Abstract
Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.
Collapse
Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Nikoletta A Theochari
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece.
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Tania Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | | | - Dimitrios Kamberoglou
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Andrianos Tsekrekos
- Division of Surgery, Department of Clinical Science Intervention and Technology, Department of Upper Abdominal Diseases, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Department of Upper Abdominal Diseases, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
10
|
Whose patient is it? The path to multidisciplinary management of achalasia. J Surg Res 2018; 228:8-13. [DOI: 10.1016/j.jss.2018.02.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 02/22/2018] [Indexed: 02/06/2023]
|
11
|
Abstract
Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction. Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease. Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.
Collapse
Affiliation(s)
- Francisco Schlottmann
- a Department of Surgery , University of North Carolina , Chapel Hill , North Carolina , USA
| | - Marco G Patti
- b Department of Medicine and Surgery, Center for Esophageal Diseases and Swallowing , University of North Carolina , Chapel Hill , North Carolina , USA
| |
Collapse
|
12
|
Barret M, Rouquette A, Massault PP, Prieux C, Brieau B, Coriat R, Chaussade S. Pseudoachalasia. Clin Res Hepatol Gastroenterol 2018; 42:99-100. [PMID: 28780054 DOI: 10.1016/j.clinre.2017.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 05/12/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Maximilien Barret
- Gastroenterology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France.
| | - Alexandre Rouquette
- Pathology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| | - Pierre-Philippe Massault
- Digestive Surgery Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| | - Caroline Prieux
- Gastroenterology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| | - Bertrand Brieau
- Gastroenterology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| | - Romain Coriat
- Gastroenterology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| | - Stanislas Chaussade
- Gastroenterology Department, Cochin University Hospital, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, France
| |
Collapse
|
13
|
Schlottmann F, Herbella F, Allaix ME, Patti MG. Modern management of esophageal achalasia: From pathophysiology to treatment. Curr Probl Surg 2018; 55:10-37. [DOI: 10.1067/j.cpsurg.2018.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
14
|
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]
|
15
|
Sutton RA, Gabbard SL. High-resolution esophageal manometry findings in malignant pseudoachalasia. Dis Esophagus 2017; 30:1-3. [PMID: 28881888 DOI: 10.1093/dote/dox095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
| | - S L Gabbard
- Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| |
Collapse
|
16
|
Ponds FA, van Raath MI, Mohamed SMM, Smout AJPM, Bredenoord AJ. Diagnostic features of malignancy-associated pseudoachalasia. Aliment Pharmacol Ther 2017; 45:1449-1458. [PMID: 28382674 DOI: 10.1111/apt.14057] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/29/2016] [Accepted: 03/04/2017] [Indexed: 12/08/2022]
Abstract
BACKGROUND Pseudoachalasia is a condition in which clinical and manometric signs of achalasia are mimicked by another abnormality, most often a malignancy. AIM To identify risk factors that suggest presence of malignancy-associated pseudoachalasia. METHODS In this retrospective cohort study, achalasia patients newly diagnosed by manometry were included. Patients with a normal initial endoscopy, clinical and manometric signs of achalasia who were afterwards found to have an underlying malignant cause were classified as pseudoachalasia. Clinical and diagnostic findings were compared between malignant pseudoachalasia and achalasia. RESULTS We included 333 achalasia patients [180 male, median age 50 (38-62)]. Malignant pseudoachalasia was diagnosed in 18 patients (5.4%). Patients with malignancy-associated pseudoachalasia were older at time of diagnosis [67 (54-71) vs. 49 (37-60) years], had a shorter duration of symptoms [6 (5-10) vs. 25 (11-60) months] and lost more weight [12 (9-17) vs. 5 (0-12) kg). In 61% of the pseudoachalasia patients, the oesophagogastric junction (OGJ) was difficult or impossible to pass during endoscopy, compared to 23% in achalasia. Age ≥55 years (OR 5.93), duration of symptoms ≤12 months (OR 14.5), weight loss ≥10 kg (OR 6.73) and difficulty passing the OGJ during endoscopy (OR 6.06) were associated with a higher risk of malignant pseudoachalasia. CONCLUSIONS Advanced age, short duration of symptoms, considerable weight loss and difficulty in passing the OGJ during endoscopy, are risk factors that suggest potential malignancy-associated pseudoachalasia. To exclude pseudoachalasia, additional investigations are warranted when two or more risk factors are present.
Collapse
Affiliation(s)
- F A Ponds
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Raath
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - S M M Mohamed
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - A J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - A J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
17
|
Schlottmann F, Shaheen NJ, Madanick RD, Patti MG. The role of Heller myotomy and POEM for nonachalasia motility disorders. Dis Esophagus 2017; 30:1-5. [PMID: 28375487 DOI: 10.1093/dote/dox003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 01/05/2017] [Indexed: 12/11/2022]
Abstract
The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.
Collapse
Affiliation(s)
- F Schlottmann
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
| | - N J Shaheen
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - R D Madanick
- Medicine and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, North Carolina, USA
| | - M G Patti
- Departments of 1Surgery and Center for Esophageal Diseases and Swallowing
| |
Collapse
|
18
|
Pediatric Hodgkin's lymphoma presenting with pseudo-achalasia and para-neoplastic neurological syndrome (Guillain-Barre): A case report. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2017. [DOI: 10.1016/j.phoj.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
19
|
Abstract
A laparoscopic Heller myotomy with partial fundoplication is considered today in most centers in the United States and abroad the treatment of choice for patients with esophageal achalasia. Even though the operation has initially a very high success rate, dysphagia eventually recurs in some patients. In these cases, it is important to perform a careful work-up to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. The best results are obtained by a team approach, in Centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this disease.
Collapse
|
20
|
Fisichella PM, Jalilvand A, Lebenthal A. Diagnostic Evaluation of Achalasia: From the Whalebone to the Chicago Classification. World J Surg 2015; 39:1593-7. [DOI: 10.1007/s00268-014-2939-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
21
|
The management of esophageal achalasia: from diagnosis to surgical treatment. Updates Surg 2013; 66:23-9. [PMID: 23817763 DOI: 10.1007/s13304-013-0224-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 06/21/2013] [Indexed: 02/07/2023]
Abstract
The goal of this review is to illustrate our approach to patients with achalasia in terms of preoperative evaluation and surgical technique. Indications, patient selection and management are herein discussed. Specifically, we illustrate the pathogenetic theories and diagnostic algorithm with current up-to-date techniques to diagnose achalasia and its manometric variants. Finally, we focus on the therapeutic approaches available today: medical and surgical. A special emphasis is given on the surgical treatment of achalasia and we provide the reader with a detailed description of our pre and postoperative management.
Collapse
|
22
|
Minimally invasive myotomy for the treatment of esophageal achalasia: evolution of the surgical procedure and the therapeutic algorithm. Surg Laparosc Endosc Percutan Tech 2012; 22:83-7. [PMID: 22487617 DOI: 10.1097/sle.0b013e318243368f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Achalasia is a rare disease of the esophagus, characterized by the absence of peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter, which may be hypertensive. The cause of this disease is unknown; therefore, the aim of the therapy is to improve esophageal emptying by eliminating the outflow resistance caused by the lower esophageal sphincter. This goal can be accomplished either by pneumatic dilatation or surgical myotomy, which are the only long-term effective therapies for achalasia. Historically, pneumatic dilatation was preferred over surgical myotomy because of the morbidity associated with a thoracotomy or a laparotomy. However, with the development of minimally invasive techniques, the surgical approach has gained widespread acceptance among patients and gastroenterologists and, consequently, the role of surgery has changed. The aim of this study was to review the changes occurred in the surgical treatment of achalasia over the last 2 decades; specifically, the development of minimally invasive techniques with the evolution from a thoracoscopic approach without an antireflux procedure to a laparoscopic myotomy with a partial fundoplication, the changes in the length of the myotomy, and the modification of the therapeutic algorithm.
Collapse
|
23
|
Triadafilopoulos G, Boeckxstaens GE, Gullo R, Patti MG, Pandolfino JE, Kahrilas PJ, Duranceau A, Jamieson G, Zaninotto G. The Kagoshima consensus on esophageal achalasia. Dis Esophagus 2012; 25:337-48. [PMID: 21595779 DOI: 10.1111/j.1442-2050.2011.01207.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal achalasia is a primary esophageal motility disorder characterized by lack of peristalsis and a lower esophageal sphincter that fails to relax appropriately in response to swallowing. This article summarizes the most salient issues in the diagnosis and management of achalasia as discussed in a symposium that took place in Kagoshima, Japan, in September 2010 under the auspices of the International Society for Diseases of the Esophagus.
Collapse
Affiliation(s)
- G Triadafilopoulos
- Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Feo CV, Caramori G, Conti V, Calia N, Guzzinati I, Ravenna F, Pasquini C, De Troia A, Liboni A, Papi A. Esophageal Achalasia with Recurrent Aspiration Pneumoniae Treated by Laparoscopic Heller Myotomy. Am Surg 2012. [DOI: 10.1177/000313481207800320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carlo V. Feo
- Dipartimento di Scienze Chirurgiche Anestesiologiche e Radiologiche Sezione di Clinica Chirurgica Università di Ferrara Ferrara, Italy
| | - Gaetano Caramori
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Valentina Conti
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Nunzio Calia
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Ippolito Guzzinati
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Franco Ravenna
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Claudio Pasquini
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| | - Alessandro De Troia
- Dipartimento di Scienze Chirurgiche Anestesiologiche e Radiologiche Sezione di Clinica Chirurgica Università di Ferrara Ferrara, Italy
| | - Alberto Liboni
- Dipartimento di Scienze Chirurgiche Anestesiologiche e Radiologiche Sezione di Clinica Chirurgica Università di Ferrara Ferrara, Italy
| | - Alberto Papi
- Dipartimento di Medicina Clinica e Sperimentale Sezione di Malattie dell'Apparato Respiratorio Università di Ferrara Ferrara, Italy
| |
Collapse
|
25
|
Stone ML, Kilic A, Jones DR, Lau CL, Kozower BD. A diagnostic consideration for all ages: pseudoachalasia in a 22-year-old male. Ann Thorac Surg 2012; 93:e11-2. [PMID: 22186482 DOI: 10.1016/j.athoracsur.2011.07.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2011] [Revised: 05/27/2011] [Accepted: 07/11/2011] [Indexed: 11/24/2022]
Abstract
Pseudoachalasia is a rare clinical diagnosis with diverse manifestations. We present the case of a 22-year-old male with esophageal adenocarcinoma who was initially diagnosed with achalasia. This unfortunate presentation reinforces the importance of a careful preoperative workup for dysphagia irrespective of age.
Collapse
Affiliation(s)
- Matthew L Stone
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0679, USA
| | | | | | | | | |
Collapse
|
26
|
Abstract
Achalasia, diffuse esophageal spasm, nutcracker esophagus, and the hypertensive lower esophageal sphincter are considered primary esophageal motility disorder. These disorders are characterized by esophageal dysmotility that is responsible for the symptoms. While there is today a reasonable consensus about the pathophysiology, the diagnosis, and the treatment of achalasia, this has not occurred for the other disorders. A careful evaluation is therefore necessary before an operation is considered.
Collapse
|
27
|
Pastor DM, Eggers AD, Drabick JJ, Loughran TP, Bayerl MG, Shope TR. Retroperitoneal Diffuse Large B-Cell Lymphoma Presenting As Pseudoachalasia. J Clin Oncol 2010; 28:e184-7. [DOI: 10.1200/jco.2009.25.8715] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Danielle M. Pastor
- Department of Surgery, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Ashley D. Eggers
- Department of Surgery, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Joseph J. Drabick
- Penn State Hershey Cancer Institute, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Thomas P. Loughran
- Penn State Hershey Cancer Institute, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Michael G. Bayerl
- Department of Pathology, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| | - Timothy R. Shope
- Department of Surgery, Pennsylvania State University Milton S. Hershey Medical Center and College of Medicine, Hershey, PA
| |
Collapse
|
28
|
Paulsen JM, Aragon GC, Ali MA, Brody FJ, Borum ML. Pseudoachalasia secondary to metastatic breast carcinoma. Dig Dis Sci 2010; 55:1179-81. [PMID: 19421854 DOI: 10.1007/s10620-009-0809-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 04/01/2009] [Indexed: 12/09/2022]
Affiliation(s)
- J M Paulsen
- Department of Internal Medicine, Division of Gastroenterology and Liver Diseases, George Washington University Medical Center, Washington, DC, USA
| | | | | | | | | |
Collapse
|
29
|
Roll GR, Rabl C, Ciovica R, Peeva S, Campos GM. A controversy that has been tough to swallow: is the treatment of achalasia now digested? J Gastrointest Surg 2010; 14 Suppl 1:S33-45. [PMID: 19760373 PMCID: PMC2825313 DOI: 10.1007/s11605-009-1013-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 08/25/2009] [Indexed: 01/31/2023]
Abstract
Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.
Collapse
Affiliation(s)
- Garrett R. Roll
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, H4/744 CSC, Madison, WI 53792-7375 USA
| | - Charlotte Rabl
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, H4/744 CSC, Madison, WI 53792-7375 USA
| | - Ruxandra Ciovica
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, H4/744 CSC, Madison, WI 53792-7375 USA
| | - Sofia Peeva
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, H4/744 CSC, Madison, WI 53792-7375 USA
| | - Guilherme M. Campos
- Department of Surgery, University of Wisconsin, School of Medicine and Public Health, 600 Highland Avenue, H4/744 CSC, Madison, WI 53792-7375 USA
| |
Collapse
|
30
|
Pseudoachalasia from gastric cancer. Clin Gastroenterol Hepatol 2009; 7:A24. [PMID: 19249400 DOI: 10.1016/j.cgh.2008.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 02/07/2023]
|
31
|
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.
Collapse
|
32
|
Lazaraki G, Nakos A, Katodritou E, Pilpilidis I, Tarpagos A, Katsos I. A rare case of multiple myeloma initially presenting with pseudoachalasia. Dis Esophagus 2008; 22:E21-4. [PMID: 19207546 DOI: 10.1111/j.1442-2050.2008.00903.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pseudoachalasia is a rare clinical entity with clinical, radiographic, and manometric features often indistinguishable from achalasia. Primary adenocarcinomas arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes of pseudoachalasia. Rarely, processes other than esophagogastric cancers including chronic idiopathic intestinal pseudo-obstruction, amyloidosis, sarcoidosis, Chagas' disease, vagotomy, antireflux surgery, pancreatic pseudocysts, von Recklinghausen's neuroinomatosis, gastrointestinal stromal tumor, and other malignancies and rare genetic syndromes, may lead to the development of pseudoachalasia. Secondary achalasia is extremely rare, with less than 100 cases reported in the literature so far. Gastrointestinal manifestations in primary or secondary amyloidosis include abdominal pain, diarrhea, constipation, malabsorption, obstruction, motility disturbance, intestinal infarction, perforation, and hemorrhage; however, gastrointestinal tract involvement is asymptomatic in most instances. We present here a rare case of multiple myeloma initially presenting with dysphagia because of esophageal amyloidosis and manometric findings typical of achalasia.
Collapse
Affiliation(s)
- Georgia Lazaraki
- Department of Gastrointestinal Oncology, Theagenion Cancer Hospital, 54248 Thessaloniki, Greece.
| | | | | | | | | | | |
Collapse
|
33
|
Achalasia of the esophagus: a surgical disease. J Am Coll Surg 2008; 208:151-62. [PMID: 19228517 DOI: 10.1016/j.jamcollsurg.2008.08.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 07/14/2008] [Accepted: 08/13/2008] [Indexed: 02/08/2023]
|
34
|
Kashyap P, Farrugia G. Enteric autoantibodies and gut motility disorders. Gastroenterol Clin North Am 2008; 37:397-410, vi-vii. [PMID: 18499027 PMCID: PMC2448392 DOI: 10.1016/j.gtc.2008.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Increasing evidence suggests that a subset of gastrointestinal motility disorders is associated with the presence of circulating antibodies. These antibodies are directed against various molecular targets, the best known being anti-neuronal nuclear antibody (ANNA-1 or anti-Hu) associated with paraneoplastic motility disorders. There is also evidence that the presence of distinct autoantibody profiles is associated with non-paraneoplastic motility disorders. This review focuses on the types of antibodies associated with gastrointestinal motility disorders and the significance of these antibodies. Algorithms are suggested for the work-up and treatment of patients with circulating antibodies associated with gastrointestinal motility disorders.
Collapse
Affiliation(s)
- Purna Kashyap
- Enteric NeuroScience Program, Mayo Clinic, Rochester, MN, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, MN
| | - Gianrico Farrugia
- Enteric NeuroScience Program, Mayo Clinic, Rochester, MN, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, MN
| |
Collapse
|
35
|
Ulla JL, Fernandez-Salgado E, Alvarez V, Ibañez A, Soto S, Carpio D, Vazquez-Sanluis J, Ledo L, Vazquez-Astray E. Pseudoachalasia of the cardia secondary to nongastrointestinal neoplasia. Dysphagia 2007; 23:122-6. [PMID: 17701248 DOI: 10.1007/s00455-007-9104-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2006] [Accepted: 05/08/2007] [Indexed: 10/23/2022]
Abstract
A minor proportion of patients with achalasia eventually have a neoplasm and, as a consequence, pseudoachalasia is diagnosed. A neoplasm may either involve gastrointestinal junction or present a paraneoplastic effect. Over the global diagnoses of achalasia issued in 5 years of experience in our motility unit, we have found 13% (3/23 cases) of pseudoachalasia (2-4% in previous series, probably due to the fact that the population assisted was mainly composed of elderly patients). The origin of the neoplasm was bladder, prostate and metastases from epidermoid carcinoma of vocal chord. Treatment of primary neoplasm, besides classical approach (with dilatation of botulinum injection) may help in the resolution of this clinical disorder.
Collapse
Affiliation(s)
- Jose Luis Ulla
- Digestive System Service, Pontevedra Hospital Complex, Pontevedra 36001, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Bonavina L, Bona D, Saino G, Clemente C. Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair. Langenbecks Arch Surg 2007; 392:653-6. [PMID: 17530282 DOI: 10.1007/s00423-007-0191-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2007] [Accepted: 02/28/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Benign esophageal pseudoachalasia is a rare condition. DISCUSSION We report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented. RESULTS Endoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen's wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.
Collapse
Affiliation(s)
- Luigi Bonavina
- Department of Medical and Surgical Sciences, Surgical Unit, I.R.C.C.S. Policlinico San Donato, University of Milan School of Medicine, Milan, Italy.
| | | | | | | |
Collapse
|
37
|
Portale G, Costantini M, Zaninotto G, Ruol A, Guirroli E, Rampado S, Ancona E. Pseudoachalasia: not only esophago-gastric cancer. Dis Esophagus 2007; 20:168-72. [PMID: 17439602 DOI: 10.1111/j.1442-2050.2007.00664.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pseudoachalasia is a rare clinical entity which has clinical, radiographic and manometric features often indistinguishable from achalasia. A small primary adenocarcinoma arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes. Rarely, processes other than esophagogastric cancers may lead to the development of pseudoachalasia. We present three cases of pseudoachalasia in which the primary cause of the disease was not an esophagogastric cancer. The causes were a pancreatic carcinoma, a breast cancer and an histiocytosis X. Aspects of these three patients' diagnostic and therapeutic course are discussed in detail.
Collapse
Affiliation(s)
- G Portale
- Istituto Oncologico Veneto (IOV-IRCCS), University of Padova, School of Medicine, Padova, Italy
| | | | | | | | | | | | | |
Collapse
|
38
|
Berindoague R, Targarona E, Pala X, Balagué C, Martinez C, Hernandez P, Agusti A, Sallent E, Mones J, Trias M. Unusual upper gastrointestinal diseases associated with achalasia: laparoscopic approach. Surg Endosc 2007; 21:719-23. [PMID: 17242987 DOI: 10.1007/s00464-006-9056-0] [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] [Received: 06/20/2006] [Revised: 06/20/2006] [Accepted: 06/30/2006] [Indexed: 01/18/2023]
Abstract
BACKGROUND As a result of the high success rate associated with the laparoscopic approach for achalasia, surgery for the disease has become the treatment of choice in recent years. With the greater number of patients undergoing surgery, surgeons may encounter other upper gastroesophageal illnesses associated with achalasia, and these may require evaluation for simultaneous surgical treatment. This study aimed to evaluate the incidence of gastroesophageal diseases associated with achalasia, and to determine the possibility for simultaneous management using the laparoscopic approach. METHODS From January 1999 to May 2006, 81 patients were referred from the Service of Gastroenterology to the Service of General and Digestive Surgery as candidates for the surgical management of achalasia. Data for this group were recorded prospectively in laparoscopic surgery databases at the Hospital Sant Pau and the Hospital de Igualada. A total of 78 patients underwent laparoscopic Heller myotomy with gastric fundoplication. RESULTS In 8 of 81 patients, nine additional gastroesophageal diseases (11.1%) were found: three cases of pseudoachalasia (3.7%), three cases of paraesophageal hiatal hernia (3.7%), two cases of esophageal diverticulum (2.5%), and one case of gastric volvulus (1.2%). Pseudoachalasia was diagnosed for three patients. The diagnosis was made preoperatively for one of these patients. For the other two patients, an adenocarcinoma arising from the gastroesophageal junction was diagnosed during the laparoscopy. In three cases, a paraesophageal hiatal hernia was found and treated by laparoscopic Heller myotomy, sac excision, hiatal closure, and posterior fundoplication. Esophageal diverticulectomy was performed for one patient. Another patient presented with an organoaxial gastric volvulus associated with achalasia, for which laparoscopic Heller myotomy, posterior fundoplication, and anterior gastropexy were performed. The median follow-up period was 39 months, with no recurrence. CONCLUSIONS Despite their infrequency, several gastroesophageal diseases may be found in association with achalasia. Laparoscopic surgery may be useful for the diagnosis and/or treatment of both diseases.
Collapse
Affiliation(s)
- R Berindoague
- Service of General and Digestive Surgery, Hospital San Pau, Barcelona, Spain.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Chuah SK, Kuo CM, Wu KL, Changchien CS, Hu TH, Wang CC, Chiu YC, Chou YP, Hsu PI, Chiu KW, Kuo CH, Chiou SS, Lee CM. Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations. World J Gastroenterol 2006; 12:5087-90. [PMID: 16937515 PMCID: PMC4087422 DOI: 10.3748/wjg.v12.i31.5087] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pseudoachalasia is a difficult condition for the clinician to differentiate from idiopathic achalasia even by manometry, radiological studies or endoscopy. Its etiology is usually associated with tumors. In most cases, the diagnosis is made after surgical explorations. The proposed pathogenesis of the disease is considered as mechanical obstruction of the distal esophagus or infiltration of the malignancy that affects the inhibitory neurons of the meyenteric plexus in the majority of cases. Surgery has been reported as a cause of pseudoachalasia. We report a 70-year-old man who suffered from deglutination disorder caused by pseudo-achalasia after truncal vagotomy. The patient was symptom-free after a nine-year follow-up and complete recovery of esophageal motility status from pseudoachalasia after pneumatic dilations. We also reviewed the literature of pseudoachalasia.
Collapse
Affiliation(s)
- Seng-Kee Chuah
- Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, ROC 833, Taiwan, China
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Gockel I, Eckardt VF, Schmitt T, Junginger T. Pseudoachalasia: a case series and analysis of the literature. Scand J Gastroenterol 2005; 40:378-85. [PMID: 16028431 DOI: 10.1080/00365520510012118] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pseudoachalasia frequently cannot be distinguished from idiopathic achalasia by manometry, radiologic examination or endoscopy. Mechanisms proposed to explain the clinical features of pseudoachalasia include a circumferential mechanical obstruction of the distal esophagus or a malignant infiltration of inhibitory neurons within the myenteric plexus. MATERIAL AND METHODS Between January 1980 and December 2002, the clinical features of 5 patients with pseudoachalasia and 174 patients with primary achalasia, diagnosed in a single center, were compared. A literature analysis of the etiology of pseudoachalasia for the time period 1968 to December 2002 was performed. The search concentrated on the databases and online catalogues PubMed, Web of Science, Cochrane Library and Current Contents Connect. RESULTS In our case series, patients with pseudoachalasia reported a shorter duration of symptoms and tended to be older than patients with primary achalasia. Conventional manometry, endoscopy and radiologic examination of the esophagus proved to be of little value in distinguishing between the diseases. In the majority of cases only surgical exploration revealed the underlying cause. A coincidence of primary achalasia and disorders of the gastroesophageal junction was excluded by showing return of peristalsis following treatment. The analysis of the literature showed a total of 264 cases of pseudoachalasia in 122 publications. Most cases of were due to malignant disease (53.9% primary and 14.9% secondary malignancy), followed by benign lesions (12.6%) and sequelae of surgical procedures at the distal esophagus or proximal stomach (11.9%). In rare instances, the disease was an expression of a paraneoplastic process due to distant neuronal involvement rather than to local invasion with destruction of the myenteric plexus (2.6%). CONCLUSIONS The diagnosis of pseudoachalasia is difficult to establish by conventional diagnostic measures. The main distinguishing feature of secondary versus primary achalasia is the complete reversal of pathologic motor phenomena following successful therapy of the underlying disorder.
Collapse
Affiliation(s)
- Ines Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg-University Mainz, Germany.
| | | | | | | |
Collapse
|
41
|
Abstract
Achalasia is a primary motility disorder of the esophagus that causes dysphagia. Normal esophageal motility and lower esophageal sphincter (LES) function can not be restored; thus treatment is directed at decreasing the pressure or disrupting the muscle fibers of the LES to allow passage of ingested material. Effective therapy for achalasia can be broadly characterized as surgery based or endoscopy based. Medications (calcium channel blockers and nitrate derivatives) do not provide adequate relief of dysphagia and have substantial side effects, and thus are rarely used as long-term therapy. Botulinum toxin injection, a recently introduced endoscopic therapy, enjoyed much enthusiasm initially but was shown to have only transient effect and is now recommended only for poor operative candidates. The mainstay of therapy remains endoscopic dilation or laparoscopic esophagomyotomy (LEM) combined with an antireflux procedure. We have found that patients who can tolerate a laparoscopic abdominal surgery are best served with an LEM and Toupet (270 degrees ) posterior fundoplication. This provides good or excellent relief of dysphagia in 90% to 95% of patients with very little morbidity.
Collapse
Affiliation(s)
- Jedediah A Kaufman
- Department of Surgery, University of Washington, 1959 NE Pacific St., Box 356410, Seattle, WA 98195-6410, USA
| | | |
Collapse
|
42
|
Seo P. Cases from the Osler Medical Service at Johns Hopkins University. Pseudoachalasia due to esophageal adenocarcinoma. Am J Med 2002; 113:522-4. [PMID: 12427504 DOI: 10.1016/s0002-9343(02)01317-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
43
|
Liu W, Fackler W, Rice TW, Richter JE, Achkar E, Goldblum JR. The pathogenesis of pseudoachalasia: a clinicopathologic study of 13 cases of a rare entity. Am J Surg Pathol 2002; 26:784-8. [PMID: 12023584 DOI: 10.1097/00000478-200206000-00013] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Pseudoachalasia is an esophageal motor disorder usually associated with malignancy that has clinical, radiographic, and manometric findings that are often indistinguishable from primary achalasia. There are few reports examining the histologic features of the associated neoplasms and their relationship with the esophageal myenteric plexus. We studied the clinical and pathologic features of 13 cases of pseudoachalasia seen at our institution between 1979 and 1999. Detailed clinical and radiographic data were obtained from medical records. In all cases available histologic material was reviewed to confirm the presence and type of associated neoplasm. When possible, the relationship of the neoplasm to the esophageal myenteric plexus was examined. In selected cases immunohistochemical stains were performed to further evaluate this relationship. All patients had clinical, radiographic, and manometric features similar to primary achalasia. The cohort included seven men and six women, age range 24-79 years (median 61 years). Associated neoplasms included esophageal adenocarcinoma arising in Barrett's esophagus (n = 1), adenocarcinoma of the esophagogastric junction (n = 7), metastatic renal cell carcinoma to the esophagogastric junction (n = 1), breast adenocarcinoma (n = 1), pulmonary small cell carcinoma (n = 1), pleural malignant mesothelioma (n = 1), and mediastinal fibrosis (n = 1). The mechanism of pseudoachalasia was consistent with neoplastic infiltration of the esophageal myenteric plexus in 11 cases. Neoplastic cells surrounded myenteric ganglion cells, which appeared normal in number and morphology. In the patient with pulmonary small cell carcinoma, there was no evidence of neoplastic infiltration of the esophagogastric junction, and anti-ANNA-1 antibody was detected, suggesting a paraneoplastic syndrome. Tissue obtained at the time of esophagomyotomy revealed lymphocytic myenteric inflammation and marked depletion of ganglion cells identical to that seen in primary achalasia. The mechanism pseudoachalasia in the patient with breast adenocarcinoma is uncertain, as there was no evidence of direct involvement of the esophagogastric junction. In summary, we describe 13 cases of pseudoachalasia resulting in a clinical syndrome indistinguishable from primary achalasia. The most common mechanism is direct involvement of the esophageal myenteric plexus by neoplastic cells. Rarely, a distant neoplasm may cause this syndrome as a paraneoplastic process.
Collapse
Affiliation(s)
- Wendy Liu
- Department of Anatomic Pathology, Cleveland Clinic Foundation, Ohio 44195, USA
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
Esophageal achalasia is a primary esophageal motility disorder of unknown etiology, characterized by absence of esophageal peristalsis and increased resting pressure of the lower esophageal sphincter (LES), which fails to relax appropriately in response to swallowing. Treatment is palliative and is directed toward elimination of the outflow resistance caused by the abnormal LES function.
Collapse
Affiliation(s)
- M G Patti
- Department of Surgery, University of California-San Francisco, 533 Parnassus Ave., San Francisco, CA 94143-0788, USA.
| | | | | |
Collapse
|
45
|
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.
Collapse
Affiliation(s)
- C Prakash
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
| | | |
Collapse
|