Multiple good options are available for achalasia management

Surgical Management of Advanced Achalasia With Sigmoid Esophagus: A Case Report

The surgical management of achalasia with sigmoid esophagus involves multiple significant challenges due to the difficulty in endoscopic assessment, esophageal motility disorders, and potential complication and recurrence rates. We report a 34-year-old female with worsening dysphagia and malnourishment due to advanced achalasia. An esophagogastroduodenoscopy (EGD) revealed an esophageal dilation, tortuosity, and distal blockage with undigested food. Esophagram demonstrated the typical bird beak appearance with a tortuous dilated esophagus. She underwent a laparoscopic Heller myotomy with Dor fundoplication with no complications. She was discharged on the second postoperative day, tolerating clear liquids, and then a normal diet within six weeks. Several treatment options exist for the surgical management of a sigmoid esophagus with achalasia, but there is no clear gold standard. In our case, Heller myotomy with Dor fundoplication provided favorable results, but treatment should be individualized for each case.

Treatment challenges of sigmoid-shaped esophagus and severe achalasia

Background

Achalasia is a chronic motility disorder which may require surgical interventions to effectively manage patients’ symptoms and improve functional status. In late stage achalasia, patients may present with sigmoid-shaped esophagus which complicates traditional treatment approaches for achalasia as the esophagus is massively dilated and dysfunctional with delicate tissue integrity. Severe Achalasia with sigmoid esophagus imposes significant challenge to surgeons and treating physicians. Various assessment modalities and treatment approaches have been tried. Surgical treatment continues to be controversial. Some have argued that a less aggressive approach similar to that in early Achalasia results in satisfactory outcomes. Others have argued a more aggressive approach of esophagectomy is necessary. We present a review of the challenges encountered in each approach with recommendation for selecting the right treatment for the individual cases.

Conclusions

Different treatment options for sigmoid type achalasia are available with ongoing controversy among the options. Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes.

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Late stage achalasia may present with sigmoid-shaped esophagus.

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Sigmoid shaped esophagus imposes significant treatment challenges due to dilation and delicate tissue integrity.

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Surgical treatment continues to be controversial.

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Heller myotomy with Dor fundoplication can provide satisfactory symptoms improvement and treatment outcomes.

Durability of pneumatic dilation monotherapy in treatment-naive achalasia patients

BACKGROUND

Pneumatic dilation (PD) is often billed as a "short term" treatment for achalasia but anecdotally can last years. This study sought to explore how long a single pneumatic dilation may induce symptom remission in a treatment-naïve achalasia patient.

METHODS

A single center, retrospective chart review of patients with an ICD-9 or - 10 code of achalasia between 2005 and 2017 was performed. Treatment naïve patients with manometric diagnosis of primary achalasia were included. Outcomes (success or failure); single vs multiple PD; age; and estimated duration of effect were evaluated. Each patient underwent a single PD unless re-intervention was required for relapse.

RESULTS

83 patients (52% female, median 51.6 ± 3.6 years) were included. 43% underwent 2 PD and 13% underwent 3 PD. There was no significant relation between age, gender, and number of PDs. After 1 PD, 87.5% of patients reported > 1 year of symptom remission. 80.5% of relapsed patients reported success after a 2nd dilation. 1 PD was more likely to result in success than multiple PDs (p < 0.001). The measured median duration of remission after 1 PD was 4.23 years, and for 2 PDs, 3.71 years. The median estimated remission time after 1 PD was 8.5 years (CI 7.3-9.7, p = 0.03).

CONCLUSIONS

PD is a safe, durable treatment for achalasia. A single PD is likely to last years. A second PD, if required, also has a high likelihood of success.