Etiology and pathogenesis of achalasia: the current understanding

Achalasia Following SARS-CoV-2 Infection: A Case Report and Review of Literature

RATIONALE

The COVID-19 pandemic caused by the SARS-CoV-2 virus has led to health complications beyond respiratory symptoms, revealing multi-organ involvement, including potential gastrointestinal implications.

PATIENT CONCERNS

We present a case of a 40-year-old female without any history of achalasia who developed symptoms of the condition following a confirmed SARS-CoV-2 infection. Unusually, multiple esophageal ulcers were identified, which are not typically associated with achalasia.

DIAGNOSIS

Achalasia and esophageal ulcers were confirmed through a series of examinations, including barium swallow, CT scan, and upper endoscopy. Furthermore, immunohistochemical staining of esophageal biopsy specimens revealed the presence of the SARS-CoV-2 spike protein, suggesting direct viral involvement.

INTERVENTIONS

The patient was treated with calcium channel blockers and proton pump inhibitors and later underwent a peroral endoscopic myotomy (POEM) procedure following the resolution of her COVID-19 infection.

OUTCOME

After the POEM procedure, the patient made a good recovery.

LESSONS

This case underscores the potential for SARS-CoV-2 to trigger gastrointestinal complications and emphasizes the need for ongoing patient management and further research into the long-term implications of COVID-19. Despite the single-case nature of this report, it contributes to the expanding understanding of the diverse and multi-systemic impact of COVID-19.

Focus on Achalasia in the Omics Era

Achalasia is a rare and complex esophageal disease of unknown etiology characterized by difficulty in swallowing due to the lack of opening of the lower esophageal sphincter and the absence of esophageal peristalsis. Recent advancements in technology for analyzing DNA, RNA and biomolecules in high-throughput techniques are offering new opportunities to better understand the etiology and the pathogenetic mechanisms underlying achalasia. Through this narrative review of the scientific literature, we aim to provide a comprehensive assessment of the state-of-the-art knowledge on omics of achalasia, with particular attention to those considered relevant to the pathogenesis of the disease. The notion and importance of the multi-omics approach, its limitations and future directions are also introduced, and it is highlighted how the integration of single omics data will lead to new insights into the development of achalasia and offer clinical tools which will allow early diagnosis and better patient management.

Recent progress of gastroesophageal reflux after endoscopic myotomy

Per-oral endoscopic myotomy (POEM) is an innovative minimally invasive technique and has emerged as the preferred modality for treating achalasia and spastic esophageal disorders in numerous specialized centers worldwide. Gastroesophageal reflux (GER) is a common complication following POEM procedures. Recently, an article in the World Journal of Gastroenterology, providing a comprehensive update on post-POEM GER. In this article, the authors present novel insights and strategies that offer valuable implications for endoscopy.

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown.

MATERIALS AND METHODS

In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified.

RESULTS

51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR.

CONCLUSIONS

A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

A Rare Coexistence: Achalasia Esophagus and Acute Intestinal Pseudo-Obstruction

Achalasia esophagus and acute intestinal pseudo-obstruction are distinct gastrointestinal motility disorders rarely found together in the same patient. We present a case of a 96-year-old woman exhibiting symptoms of both conditions, including dysphagia, regurgitation, abdominal distension, nausea, vomiting, and constipation. Diagnostic evaluations revealed esophageal dilation with a "bird beak" sign on timed barium swallows and significant bowel dilation without mechanical obstruction on computed tomography scans. Treatment involved conservative measures for acute intestinal pseudo-obstruction and palliative approaches for achalasia esophagus. The coexistence of these disorders raises questions about potential shared pathophysiological mechanisms involving the enteric nervous system or smooth muscle dysfunction. Further research is warranted to elucidate these connections and improve management strategies for such complex cases.

Cardiovascular Autonomic Deficits in Different Types of Achalasia

Background and objective Achalasia cardia is a primary esophageal motility disorder, and the etiopathology of this disease's progression is not known. Moreover, autonomic dysfunction has not been studied in different types of achalasia. In light of this, we aimed to address this lack of data in this study. Methods The diagnosis of achalasia was done using high-resolution esophageal manometry (HRM)-based Chicago classification v4.0. Autonomic function tests (AFT) such as the head-up tilt test, deep breathing test (DBT), Valsalva maneuver (VM), handgrip test (HGT), and cold pressor test (CPT), as well as the heart rate variability (HRV) test, were performed among the cohort and the results were compared with those of 39 age- and sex-matched healthy controls. Results AFT and HRV tests were done on 62 patients (30 achalasia type I, 28 type II, and 4 type III) and compared with 39 age- and sex-matched healthy controls. The mean duration of symptoms, high Eckardt score, and dysphagia were most common in type I achalasia, followed by type II and III. The results of AFT showed a generalized loss of parasympathetic and baroreflex-independent sympathetic reactivity in all types of achalasia. However, baroreflex-dependent cardiovascular adrenergic reactivity was normal. Regarding cardiac autonomic tone, there was a loss of parasympathetic and sympathetic influence, but sympathovagal balance was maintained. The severity of the loss of autonomic functions was higher in type I, followed by type II. Conclusions In all types of achalasia, parasympathetic reactivity, baroreflex-independent sympathetic reactivity, and cardiac autonomic tone were lower compared to healthy controls, and the severity of dysfunction increased during the progression of the disease from type II to type I.

Fifteen-year symptomatic outcome of patients with nonactionable motor findings on high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) is performed for evaluation of esophageal symptoms, but patient outcome is unclear when no actionable motor disorder is identified. We evaluated long-term symptomatic outcome of patients with nonactionable HRM findings.

METHODS

Patients who underwent (HRM) studies in 2006-2008 were tracked. Patients with achalasia spectrum disorders, foregut surgery before or after HRM, and incomplete symptom documentation were excluded. Symptom questionnaires assessing dominant symptom intensity (DSI, product of symptom severity and frequency recorded on 5-point Likert scales) and global symptom severity (GSS, from 10 cm visual analog scale) were repeated. Change in symptom burden was compared against HRM motor findings using Chicago Classification 4.0 (CCv4.0), applied retroactively to 2006-2008 data.

KEY RESULTS

Overall, 134 patients (median age 68 years, 64.5% female) could be contacted. The majority (73.1%) had normal motility; others had ineffective esophageal motility (8.2%), esophagogastric junction outflow obstruction (13.4%), hypercontractile esophagus (3.0%), or absent contractility (2.2%), none managed invasively. Over 15 years of follow-up, DSI decreased from 8.0 (4.0-16.0) to 1.0 (0.0-6.0) (p < 0.001) and GSS improved from 5.5 (3.3-7.7) to 2.0 (0.0-4.0) (p < 0.001); improvement was consistent across CCv4.0 diagnoses and subgroups. The majority (82.8%) reported improvement over time, and antisecretory medication was the most effective intervention (83.0% improvement). There was no difference in medication efficacy (p = 0.75) or improvement in symptoms (p = 0.20) based on CCv4 diagnosis.

CONCLUSIONS AND INFERENCES

Esophageal symptoms improve with conservative symptomatic management over long-term follow-up when no conclusive obstructive motor disorders or achalasia spectrum disorders are found on HRM.

Exploring the neural mechanisms underlying achalasia: A study of functional connectivity and regional brain activity

BACKGROUND AND AIMS

The pathophysiology of achalasia, which involves central nuclei abnormalities, remains unknown. We investigated the resting-state functional MRI (rs-fMRI) features of patients with achalasia.

METHODS

We applied resting-state functional MRI (rs-fMRI) to investigate the brain features in patients with achalasia (n = 27), compared to healthy controls (n = 29). Focusing on three regions of interest (ROIs): the dorsal motor nucleus of the vagus (DMV), the nucleus ambiguus (NA), and the nucleus of the solitary tract (NTS), we analyzed variations in resting-state functional connectivity (rs-FC), fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo).

RESULTS

Achalasia patients demonstrated stronger functional connectivity between the NA and the right precentral gyrus, left postcentral gyrus, and left insula. No significant changes were found in the DMV or NTS. The fMRI analysis showed higher rs-FC values for NA-DMV and NA-NTS connections in achalasia patients. Achalasia patients exhibited decreased fALFF values in the NA, DMV, and NTS regions, as well as increased ReHo values in the NA and DMV regions. A positive correlation was observed between fALFF values in all six ROIs and the width of the barium meal. The NTS fALFF value and NA ReHo value displayed a positive correlation with integrated relaxation pressure (IRP), while the ReHo value in the right precentral gyrus showed an inverse correlation with the height of the barium meal.

CONCLUSIONS

Abnormal rs-FC and regional brain activity was found in patients with achalasia. Our study provides new insights into the pathophysiology of achalasia and highlights the potential of rs-fMRI in improving the diagnosis and treatment of this condition.

Mini-review: Tailored per-oral endoscopic myotomy for type III achalasia

This mini-review summarizes the most recent literature regarding per-oral endoscopic myotomy for type III achalasia, emphasizing the poorly understood science of tailoring myotomy length during this procedure. In addition, special attention will be placed on the current subjective and objective biomarkers, such as the Eckardt score, used to evaluate treatment outcomes in this population to better contextualize the existing data on patient outcomes, as proposed by Low et al in the current issue of the Journal. Understanding the current treatment landscape for type III achalasia and identifying the key areas of research deficiencies will guide future investigation and management of this disease.

Familial achalasia isolated or syndromic: about 18 families

Aim: Familial achalasia (FA) is a very rare condition. This work aims to evaluate its prevalence, characterize its clinical profile in a large series, and assess the efficacy and safety of pneumatic dilation (PD) in this context. Methods: A total of 817 patients with achalasia were collected over a period of 20 years (1990–2010). All cases of FA: isolated or associated to Allgrove syndrome, were looked for in both parents and siblings. Results: In this study, 18 families with FA were identified n = 41 patients (5%). Two members were affected in each family, in 14 families, three members per family in three others, and for the remaining family 04 members. All cases of achalasia were observed in siblings and parent to child transmission was unfound. Achalasia was associated to Allgrove syndrome in 15 families. It was isolated in 3 families. Consanguinity was found in 89% of patients, and death at a young age in the siblings was recorded in 27% of cases. Achalasia was present before the age of 5 years in 75% of cases. There was no difference between the two groups for age, age at onset, sex and the presence of the cardinal signs of achalasia. A total of 102 dilations were performed. Only one session in 31% of cases, two in 38%, three in 17% and more than three sessions in 14%. The long-term success rate of PD was low. Conclusions: FA manifests almost exclusively in childhood. It is rarely isolated; most often falls under Allgrove syndrome. Alacrima is the earliest sign that should lead to the diagnosis. The long-term success rate of PD is rather low. This requires recourse to multiple sessions of PD or Heller’s cardiomyotomy which may be the best initial approach.

Familial achalasia isolated or syndromic: about 18 families

Aim: Familial achalasia (FA) is a very rare condition. This work aims to evaluate its prevalence, characterize its clinical profile in a large series, and assess the efficacy and safety of pneumatic dilation (PD) in this context. Methods: A total of 817 patients with achalasia were collected over a period of 20 years (1990–2010). All cases of FA: isolated or associated to Allgrove syndrome, were looked for in both parents and siblings. Results: In this study, 18 families with FA were identified n = 41 patients (5%). Two members were affected in each family, in 14 families, three members per family in three others, and for the remaining family 04 members. All cases of achalasia were observed in siblings and parent to child transmission was unfound. Achalasia was associated to Allgrove syndrome in 15 families. It was isolated in 3 families. Consanguinity was found in 89% of patients, and death at a young age in the siblings was recorded in 27% of cases. Achalasia was present before the age of 5 years in 75% of cases. There was no difference between the two groups for age, age at onset, sex and the presence of the cardinal signs of achalasia. A total of 102 dilations were performed. Only one session in 31% of cases, two in 38%, three in 17% and more than three sessions in 14%. The long-term success rate of PD was low. Conclusions: FA manifests almost exclusively in childhood. It is rarely isolated; most often falls under Allgrove syndrome. Alacrima is the earliest sign that should lead to the diagnosis. The long-term success rate of PD is rather low. This requires recourse to multiple sessions of PD or Heller’s cardiomyotomy which may be the best initial approach.

Role of endoscopy in patients with achalasia

Achalasia is an esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and peristalsis of the esophageal body. With the increasing prevalence of achalasia, interest in the role of endoscopy in its diagnosis, treatment, and monitoring is also growing. The major diagnostic modalities for achalasia include high-resolution manometry, esophagogastroduodenoscopy, and barium esophagography. Endoscopic assessment is important for early diagnosis to rule out diseases that mimic achalasia symptoms, such as pseudo-achalasia, esophageal cancer, esophageal webs, and eosinophilic esophagitis. The major endoscopic characteristics suggestive of achalasia include a widened esophageal lumen and food residue in the esophagus. Once diagnosed, achalasia can be treated either endoscopically or surgically. The preference for endoscopic treatment is increasing owing to its minimal invasiveness. Botulinum toxins, pneumatic balloon dilation, and peroral endoscopic myotomy (POEM) are important endoscopic treatments. Previous studies have demonstrated excellent treatment outcomes for POEM, with >95% improvement in dysphagia, making POEM the mainstay treatment option for achalasia. Several studies have reported an increased risk of esophageal cancer in patients with achalasia. However, routine endoscopic surveillance remains controversial owing to the lack of sufficient data. Further studies on surveillance methods and duration are warranted to establish concordant guidelines for the endoscopic surveillance of achalasia.

The correlation between helicobacter pylori and idiopathic achalasia: A case control study

Background

Idiopathic achalasia is a common and well-recognized primary esophageal motility disorder with unknown etiology and is characterized by the abnormality of esophageal body peristalsis associated with an impaired relaxation of the lower esophageal sphincter (LES). The aim of this study is to explore the correlation between Helicobacter pylori and idiopathic achalasia.

Methods

This study was conducted on 700 patients, with dysphagia, regurgitation, and non-cardiac chest pain (NCCP), who met our inclusion criteria. The mean ± SD age was 39.8 ± 11 (13-80 years), and 60% (420) of the participants were female. Of the participants, 108 had idiopathic achalasia and 105 were normal participants who were placed in the case and control groups, respectively. They were enrolled in the study based on high-resolution manometry. H. pylori was confirmed by a histological study. In the biopsy, specimens were taken by esophagogastroduodenoscopy.

Results

Our results revealed that 71.3% and 45% of the participants were H. Pylori positive in the case and control groups, respectively. The odds ratio (OR) was 3.3 (95% CI: 1.80-5.99, P < 0.05), indicating a statistically significant association between H. Pylori infection and the group classification. The dominant presenting symptoms in achalasia were dysphagia (97.2%) and NCCP (80.5%), but regurgitation (65.7%) was a dominant symptom in the normal participants.

Conclusions and Inferences

Diverse autoimmune and apoptotic phenomena induced by H. Pylori influence the pathogenesis of idiopathic achalasia, suggesting an underlying link between H. Pylori infection and idiopathic achalasia. This correlation should be confirmed by other clinical and experimental studies.

Early esophageal carcinomas in achalasia patient after endoscopic submucosal dissection combined with peroral endoscopic myotomy: A case report

BACKGROUND

Achalasia is associated with high risk of esophageal carcinoma. However, the optimal endoscopic surgery for patients with early esophageal carcinoma concomitant with achalasia remains unclear.

CASE SUMMARY

A combination of concurrent endoscopic submucosal dissection (ESD) and modified peroral endoscopic myotomy (POEM) was performed on a 62-year-old male, who presented with multiple early esophageal carcinomas concomitant with achalasia. The patient exhibited an improvement in feeding obstruction, and presented no evidence of disease during the 3-year follow-up.

CONCLUSION

The combination of ESD and POEM is a feasible treatment modality for patients with early esophageal carcinoma concomitant with achalasia.

Early esophageal carcinomas in achalasia patient after endoscopic submucosal dissection combined with peroral endoscopic myotomy: A case report

BACKGROUND

Achalasia is associated with high risk of esophageal carcinoma. However, the optimal endoscopic surgery for patients with early esophageal carcinoma concomitant with achalasia remains unclear.

CASE SUMMARY

A combination of concurrent endoscopic submucosal dissection (ESD) and modified peroral endoscopic myotomy (POEM) was performed on a 62-year-old male, who presented with multiple early esophageal carcinomas concomitant with achalasia. The patient exhibited an improvement in feeding obstruction, and presented no evidence of disease during the 3-year follow-up.

CONCLUSION

The combination of ESD and POEM is a feasible treatment modality for patients with early esophageal carcinoma concomitant with achalasia.

True peristaltic recovery is uncommon following treatment, particularly endoscopic dilation for achalasia cardia, though pseudo-recovery often occurs

BACKGROUND

Relieving esophagogastric junction (EGJ) obstruction has been the focus of treatment for achalasia cardia. The recovery of peristalsis has been an elusive goal. Studies analyzing post-intervention peristaltic recovery have several limitations such as the use of conventional manometry or lack of standard definitions of peristalsis. Accordingly, we undertook this study to analyze frequency and pattern of peristaltic recovery following treatment for achalasia cardia on high-resolution manometry (HRM) and standard Chicago definition of peristalsis.

METHODS

Pre and post-intervention HRM records of 71 treatment-naive patients diagnosed as achalasia cardia were retrospectively analyzed. Records with pre and post-intervention HRM on different systems (e.g. solid state and water perfusion) and those with inadequate information were excluded. All HRMs were interpreted as per Chicago classification version 3.0. After pneumatic dilation (PD) or laparoscopic Heller's myotomy (LHM), pseudorecovery of peristalsis was defined as any contraction at least 3 cm in length along 20 mmHg isobaric contour with a distal latency of less than 4.5 seconds. True recovery and premature contractions were defined by standard Chicago classification v3.0 criteria.

RESULTS

Change in diagnosis was observed in 38 of 71 (53.5%) patients after intervention. While pseudo-peristaltic recovery occurred in 11 of 71 (15.5%) patients, only three (4.2%) had a true recovery. Another nine (12.7%) patients showed new premature contractions.

CONCLUSION

True peristaltic recovery is uncommon in achalasia cardia following intervention, particularly PD. Pseudo-peristaltic recovery is more common. Further research is warranted on this issue.

Cancer and Trypanosoma cruzi: Tumor induction or protection?

Trypanosoma cruzi causes Chagas disease, a neglected disease that can be divided, overall, into acute and chronic phases. Understanding the mechanisms underlying its progression is based on the parasite-host interactions occurring during the infection. Although the pathophysiology of the main symptomatic forms of Chagas disease has been the subject of several studies, little is known about their relationship with the development of different types of cancer. Therefore, knowledge regarding the molecular aspects of infection in the host, as well as the influence of the immune response in the parasite and the host, can help to understand the association between Chagas disease and tumor development. This review aims to summarize the main molecular mechanisms related to T. cruzi-dependent carcinogenic development and the mechanisms associated with tumor protection mediated by different parasite components.

Update on the Diagnosis and Treatment of Achalasia

Achalasia is a rare disease of the esophagus with impaired relaxation of the lower esophageal sphincter and aperistalsis. The etiology is unknown but speculations include a viral or autoimmune etiology. All specialists dealing with swallowing and esophageal diseases should recognize the classic symptoms of dysphagia for solids/liquids, regurgitation, and choking, especially at night. High-resolution manometry is critical for the diagnosis with endoscopy and barium esophagram having a supportive role. The disease cannot be cured but most can return to near normal swallowing and a regular diet with appropriate therapy. Treatment includes smooth muscle relaxants, botulinum toxin injections to the lower sphincter, pneumatic dilation, Heller myotomy, and peroral endoscopic myotomy. One treatment does not fit all and a tailored approach through a multidiscipline team will give the best long-term outcomes.

Burn Pits: A Possible Trigger for Achalasia

A 45-year-old female veteran of the United States Air Force (USAF), who was exposed to burn pits on multiple occasions while deployed in the Middle East, presented for a second opinion regarding ongoing chest pain and regurgitation after a Heller myotomy for achalasia. An esophageal X-ray showed no meaningful peristalsis, a slight diverticulum in the distal esophagus, and easy passage of liquids through the lower esophageal sphincter (LES). Esophageal manometry findings were consistent with type 3 achalasia. Based on these and endoscopic evaluation, the prior surgical intervention appeared to be successful for lower esophageal sphincter disruption, so symptoms were managed medically with a proton pump inhibitor, trazodone, and a long-acting nitrate resulting in 70% improvement. We present this case because the patient developed achalasia with a notable history of exposure to open-air burn pits during her military service. While we acknowledge that causality cannot be proven, our case is the first we are aware of that shows a temporal association between burn pit exposure and achalasia. In August of 2022, the United States Congress passed the Promise to Address Comprehensive Toxics (PACT) Act, which expanded the healthcare benefits of veterans exposed to burn pits, making identification of associated conditions a relevant and important endeavor.

A cross-sectional study reveals a chronic low-grade inflammation in achalasia

BACKGROUND AND AIM

Immune-mediated neuroinflammation has been proposed to underlie the loss of lower esophageal sphincter (LES) myenteric neurons in achalasia. However, the immune status and key pathogenic immune subpopulations remain unclear. This study aims to evaluate the inflammatory status of patients with achalasia and their correlation with clinical characteristics, and further explore the key pathogenic subpopulations.

METHODS

We investigated the complete blood cell count and inflammatory markers in a large population of patients with achalasia (n = 341) and healthy controls (n = 80). The subpopulations of lymphocytes were analyzed by flow cytometry. Immunofluorescence was used to determine immune cell infiltration in the LES. Transcriptome changes of the key subpopulation were determined by RNA sequencing analysis.

RESULTS

NLR, MLR, CRP, globulin, IL-6 and IL-10 were significantly elevated in patients with achalasia. MLR and globulin were positively correlated with disease duration. The absolute count and percentage of CD8+ T cells in peripheral blood and its infiltration around ganglion in the LES were significantly increased in achalasia. Transcriptome analysis indicated that CD8+ T cells were activated and proliferative. In addition to multiple inflammatory pathways, regulation of neuroinflammatory response pathway was also significantly up-regulated in achalasia. GSEA analysis revealed a close association with autoimmune diseases.

CONCLUSIONS

Patients with achalasia suffered from chronic low-grade inflammation with dysregulated immune cells and mediators associated with disease duration. CD8+ T cells might be the key pathogenic subpopulation of achalasia. Our results provide an important immune cell signature of the pathogenesis of achalasia.

Patients with dysphagia: How to supply nutrition through non-tube feeding

OBJECTIVE

Dysphagia has become one of the important factors that cause malnutrition in the whole age group. At present, tube feeding is still the mainstream means to solve the problem of dysphagia. However, tube feeding has physical and mental harm to people, and the ways of non-tube feeding are relatively diversified. The significance of the thickening mechanism described in some articles to solve the problem of dysphagia is not clear.

SETTING AND PARTICIPANTS

All patients with dysphagia worldwide, including oropharyngeal dysphagia (OD) and non-oropharyngeal dysphagia.

METHODS

We searched the literature in Pubmed, Web of Science and Cochrane Library and initially browsed the titles and abstracts. We reviewed the full text of the articles that met our topic, and the language of the article was limited to English.

RESULTS

We found that food thickening to a certain degree (350-1,750 cP) can reduce the complications of choking, aspiration, reflux, and other complications in patients with dysphagia, and reduce the social disorder, anxiety, and other psychological problems caused by catheterization and surgery. Significantly, food science engineers should invite clinicians to intervene in the development of specialty foods from different perspectives such as clinical pathophysiology and fluid mechanics.

CONCLUSION AND IMPLICATIONS

It is necessary to develop special foods for patients with dysphagia, which requires scientists from different disciplines to work together.

Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis

BACKGROUND

Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.

AIM

To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events.

METHODS

We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI).

RESULTS

We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95).

CONCLUSION

Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Prevalence of neurodegenerative/demyelinating disorders in patients with achalasia

Introduction

Esophageal achalasia is a primary motility disorder. Although the exact pathogenesis is unknown, autoimmune, and neurodegenerative processes seem to be involved similarly to neurodegenerative and/or demyelinating disorders (NDDs). We hypothesized that the prevalence of NDD may be higher among patients with achalasia and vice versa as the background pathogenetic mechanisms are similar.

Methods

This was a prospective, comparative questionnaire-based study. Patients with achalasia and patients with NDD were enrolled. Selected patients with achalasia were thoroughly examined by a neurologist and selected patients with NDD were examined by a gastroenterologist to confirm or rule out NDD or achalasia. We assessed the prevalence of both achalasia and NDD and compared them with their prevalence in general population.

Results

A total of 150 patients with achalasia and 112 patients with NDD were enrolled. We observed an increased prevalence of NDD among patients with achalasia (6.0% (9/150); 95% CI (confidence interval): 3.1–11.2%) as compared to the estimated 2.0% prevalence in general population (p = 0.003). Although 32 out of 112 patients (28.6%) with NDD reported dysphagia, we did not observe significantly increased prevalence of achalasia in these patients (1.8% (2/112) vs 0.8% in general population, p = 0.226).

Conclusion

The prevalence of NDD was significantly higher among patients with achalasia (6.0%) compared to general population (2.0%), suggesting an association of these disorders. Large-volume studies are necessary to confirm this finding.

Autoimmune and viral risk factors are associated with achalasia: A case-control study

BACKGROUND

Achalasia is a rare esophageal motility disorder of uncertain etiology. While past studies have indicated that autoimmune conditions and viral infections may be associated with development of achalasia, these associations are yet to be examined in large, population-based studies.

METHODS

A matched case-control study was performed using administrative claim data from the IBM MarketScan Commercial Claims and Encounters Database between 2000 and 2019. A history of selected autoimmune conditions and viral infections was assessed using past medical claims. Multivariable conditional logistic regression was used to account for the matched nature of the study design and further control for confounding by demographic and clinical characteristics when reporting adjusted odds ratios (aORs).

KEY RESULTS

Among 6769 cases and 27,076 controls, presence of any of the autoimmune conditions studied was associated with increased odds of achalasia (aOR = 1.26, 95% CI: 1.11, 1.42). Scleroderma or systemic sclerosis (aOR = 8.13, 95% CI: 3.34, 19.80) and Addison's disease (aOR = 3.83, 95% CI: 1.83, 8.04) had the strongest associations with achalasia. Presence of any of the viral infections studied was also associated with an increased risk of achalasia (aOR = 1.58, 95% CI: 1.23, 2.01). Varicella zoster virus (aOR = 3.84, 95% CI: 1.94, 7.62) and human papillomavirus (aOR = 1.77, 95% CI: 1.15, 2.73) both had strong relationships with achalasia.

CONCLUSIONS AND INFERENCES

These findings suggest that achalasia may have autoimmune and viral components contributing to its etiology. Future mechanistic studies could target specific diseases and agents highlighted by this research.

Esophageal carcinoma in achalasia patients managed with endoscopic submucosal dissection and peroral endoscopic myotomy: Japan Achalasia Multicenter Study

OBJECTIVES

Indications for peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) in patients with achalasia concomitant with esophageal carcinoma (EC) are unclear. This study aimed to clarify the role of POEM in cases of achalasia concomitant with EC and to elucidate the indications for ESD and efficient surveillance for EC.

METHODS

We conducted a multicenter cohort study at 14 hospitals in Japan, including 3707 cases of achalasia-related esophageal motility disorders (EMDs). Factors contributing to EC risk, the characteristics of EC, and clinical outcomes of POEM/ESD were analyzed.

RESULTS

In patients undergoing POEM, screening and surveillance endoscopy throughout a 1-year period resulted in diagnosis of 72.1% new EC cases. Of 62 patients with 123 ECs, 40.3% had multiple or metachronous lesions within 37.5 months. EC was predominantly observed in the middle thoracic esophagus (58.5%) and posteriorly (73.2%). POEM had comparable safety and efficacy in cases of concomitant EC even after ESD. Endoscopic en bloc resection was performed in 95.8% and 89.3% of ECs diagnosed before and after POEM, respectively (P = 0.351); however, ESD on the POEM-line was impaired by fibrosis. Multivariate analysis revealed risk factors for EC, including regular alcohol consumption, a history of smoking, advanced age, and extended disease duration. Alcohol intake and smoking had a synergistic effect on EC development.

CONCLUSIONS

Screening and surveillance of POEM help in detecting EC. ESD is feasible in achalasia, although on the POEM-line is challenging. Surveillance endoscopy for EC is recommended for cases with specific risks and a history of ECs.

Development of Achalasia in a Patient With Chronic Intestinal Pseudo-Obstruction

Development of concurrent achalasia and chronic intestinal pseudo-obstruction (CIPO) is rare, although esophageal dysmotility is common in patients with CIPO and may suggest worse clinical outcomes. We present a case of a 63-year-old man with a 15-year history of CIPO who developed postprandial regurgitation, vomiting, and dysphagia and was diagnosed with achalasia through radiographic and endoscopic findings. This is only the third case in the reported literature that involves both conditions. Rather than representing 2 separate disorders, CIPO and achalasia may instead represent neurogenic variants of 1 underlying condition affecting the myenteric plexus.

Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Dysphagia is a common symptom with significant impact on quality of life. Our diagnostic armamentarium was primarily limited to endoscopy and barium esophagram until the advent of manometric techniques in the 1970s, which provided the first reliable tool for assessment of esophageal motor function. Since that time, significant advances have been made over the last 3 decades in our understanding of various esophageal motility disorders due to improvement in diagnostics with high-resolution esophageal manometry. High-resolution esophageal manometry has improved the sensitivity for detecting achalasia and has also enhanced our understanding of spastic and hypomotility disorders of the esophageal body. In this review, we discuss the current approach to diagnosis and therapeutics of various esophageal motility disorders.

Childhood esophageal achalasia: Case report from Afghanistan with literature review

Introduction and importance

Esophageal achalasia is a motility disorder of the esophagus with unknown etiology characterized by the failure of lower esophageal sphincter relaxation. Diagnosis is made by barium esophagography, endoscopy, and esophageal manometery. Heller Esophagomyotomy along with Dor's fundoplication is the treatment of choice. Persisting undiagnosed cases may lead to malnutrition.

Case presentation

We present a case of an 8-year-old child suffering from dysphagia and regurgitation. The child was misdiagnosed and maltreated for the suspicion of respiratory tract and gastrointestinal problems in the local clinics. During this time, he remained unresponsive to the mentioned treatments, and the local physician advised him to have an upper gastrointestinal (GI) endoscopy, which revealed esophageal achalasia (EA).

On admission to our pediatric surgery ward, the patient had coexistent parotitis, which was treated conservatively. Following recovery, the patient was prepared for surgery and underwent esophageal myotomy along with Dor's fundoplication.

Clinical discussion

Esophageal achalasia is rare in children, but poses major health challenges to children if left untreated. Symptomatic treatment may mask the actual picture of the problem and last for years. Following surgery and discharge from the hospital in a three-month follow-up interval of time, our patient exhibited full recovery, with gaining 4 kg weight.

Conclusions

Respiratory and gastrointestinal conditions with similar signs and symptoms should always be considered in differential diagnosis of esophageal achalasia, especially where there is no direct access to a pediatric specialized complex. On-time evaluation and treatment will further prevent children from malnutrition in long-lasting undiagnosed patients.

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Esophageal achalasia is a motility disorder with unknown etiology.

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Esophageal achalasia is rare in children.

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Dysphagia and respiratory infection will mask the actual picture of the problem.

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Unprofessional symptomatic treatment for a long time is the main cause of undiagnosed patient and may lead to malnutrition.

LncRNA expression in idiopathic achalasia: New insight and preliminary exploration into pathogenesis

Idiopathic achalasia is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES). However, the pathogenesis of idiopathic achalasia remains unclear. To further understand the pathogenesis, we conducted lncRNA and mRNA microarray analyses. LES specimens from 5 patients and 4 controls were used for microarray. Potential target genes with significantly changed lncRNA and mRNA were predicted using cis/trans-regulatory algorithms, followed by the Gene Ontology and KEGG pathway enrichment analysis to understand the biophysical effect. Finally, 7,133 significantly dysregulated mRNAs (3,136 increased and 3,997 decreased), along with 6,892 significantly dysregulated lncRNAs (4,900 increased and 1,992 decreased). Biophysical function analysis revealed that the cell adhesion molecule (CAM) pathway was a common pathway. The predicted lncRNA targets of NRXN1 (Down FC: 9.07), NTNG2 (UP FC: 2.75), CADM1 (Down FC: 2.26), NLGN1 (Down FC: 4.60), NEGR1 (Down FC: 2.335), CD22 (Down FC: 5.62), HLA-DQB1 (Down FC: 5.06), and HLA-DOA (Down FC: 2.31) were inputted in this pathway, which was mainly located in the synapse part of the neural system and immune system. Our study demonstrates the lncRNAs and corresponding mRNAs that may play important roles in idiopathic achalasia.

Pneumatic dilation for esophageal achalasia: patient selection and perspectives

Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and impaired relaxation of the lower esophageal sphincter. Treatment is palliative, aimed at decreasing the lower esophageal sphincter pressure. Pneumatic dilation (PD) is a safe and effective treatment for achalasia. Several other invasive and minimally invasive treatment modalities, such as Laparoscopic Heller Myotomy (LHM) and Peroral Endoscopic Myotomy (POEM), also have a comparable safety and efficacy profile to PD. The current review focuses on the indications, contraindications, techniques, and outcomes of PD in various patient populations and its comparison to LHM and POEM. This review also provides relevant information to help endoscopists identify those patients who will benefit the most from PD.

Esophageal achalasia in an adolescent in Central Africa: a case report

Esophageal Achalasia has rarely been reported in sub-Saharan Africa. We report a case of a 12 years old boy who has been diagnosed after experiencing dysphagia for a year and progressive wasting. Esophagogram was the only exploration available in our settings and showed classical features. He underwent a Heller esophago-cardiomyotomy with Toupet fundoplication. Postoperative period was unremarkable and BMI normalized for age and sex on the sixth postoperative month. In low settings, history is a key step which lead to clinical suspicion as esophagogram is often the only available exploration to confirm the diagnosis.

Pathophysiology of Dysphagia in Eosinophilic Esophagitis: Causes, Consequences, and Management

Eosinophilic esophagitis (EoE) is a leading cause of food bolus impaction in children and adults. The mechanism of dysphagia in EoE, particularly non-obstructive dysphagia, remains incompletely understood. While fibrostenotic processes appear to be critical in the development of dysphagia, somatosensory dysfunction and dysmotility also contribute. This review considers potential mechanisms of dysphagia and evaluates the utility of current and future treatment strategies in this context.

To Wrap or Not to Wrap After Heller Myotomy

Background and Objectives:

The primary aim of this study is to assess the necessity of fundoplication for reflux in patients undergoing Heller myotomy for achalasia. The secondary aim is to assess the safety of the robotic approach to Heller myotomy.

Methods:

This is a single institution, retrospective analysis of 61 patients who underwent robotic Heller myotomy with or without fundoplication over a 4-year period (January 1, 2015 – December 31, 2019). Symptoms were evaluated using pre-operative and postoperative Eckardt scores at < 2 weeks (short-term) and 4 – 55 months (long-term) postoperatively. Incidence of gastroesophageal reflux and use of antacids postoperatively were assessed. Long-term patient satisfaction and quality of life (QOL) were assessed with a phone survey. Finally, the perioperative safety profile of robotic Heller myotomy was evaluated.

Results:

The long-term average Eckardt score in patients undergoing Heller myotomy without fundoplication was notably lower than in patients with a fundoplication (0.72 vs 2.44). Gastroesophageal reflux rates were lower in patient without a fundoplication (16.0% vs 33.3%). Additionally, dysphagia rates were lower in patients without a fundoplication (32.0% vs 44.4%). Only 34.8% (8/25) of patients without fundoplication continued use of antacids in the long-term. There were no mortalities and a 4.2% complication rate with two delayed leaks.

Conclusion:

Robotic Heller myotomy without fundoplication is safe and effective for achalasia. The rate of reflux symptoms and overall Eckardt scores were low postoperatively. Great patient satisfaction and QOL were observed in the long term. Our results suggest that fundoplication is unnecessary when performing Heller myotomy.

The effects of acetylcholine on intracellular calcium fluorescence in smooth muscle cells of human esophagogastric junction cultured in vitro

BACKGROUND

Most esophageal motility studies are based on animals. It is necessary to explore smooth muscle motility in the human esophagus. This study was undertaken to explore the feasibility of in vitro culture of smooth muscle cells (SMCs) from human esophagogastric junction (EGJ) and to determine changes of intracellular calcium (Ca²⁺ ) fluorescence ([Ca²⁺ ]_i ) in SMCs stimulated by acetylcholine (ACh).

METHODS

Primary cells of EGJ (Clasp, Sling, esophageal circular muscle (ECM), and longitudinal muscle (ELM)) were obtained by enzymatic digestion (ED) and explant culture with tissues (EC-T) from 9 upper esophageal carcinoma patients. Cells were cultured in smooth muscle cell medium (SMCM) and DMEM/F-12 medium containing 10% newborn bovine serum (10%-F12), respectively, and then identified by α-SMA staining. After incubation with 5 μM Fluo-3/am, the effect of 10^-6  mM ACh on [Ca²⁺ ]_i in Ca²⁺ -containing and Ca²⁺ -free buffers was evaluated by confocal microscopy.

RESULTS

Cultured cells from ED and EC-T were identified as SMCs by α-SMA with spindle surface and "hills and valleys" morphology. Cells cultured in 10%-F12 showed better morphology. The main characteristic of [Ca²⁺ ]_i in Clasp-, Sling- and ECM-SMCs was the release of intracellular Ca²⁺ stores; the main characteristic in ELM-SMCs was extracellular Ca²⁺ influx. However, these cells seemed not to rely on a unique Ca²⁺ activity, instead combining the two activities to maintain [Ca²⁺ ]_i .

CONCLUSIONS

It was feasible to culture human EGJ SMCs in vitro; moreover, Ach-induced changes of [Ca²⁺ ]_i in EGJ SMCs represent a complex interaction of intracellular Ca²⁺ release and extracellular Ca²⁺ influx.

Circulating levels of cytokines, chemokines and growth factors in patients with achalasia

Idiopathic achalasia is a disease that is characterized by the absence of peristalsis and incomplete relaxation of the lower esophageal sphincter, which is accompanied by dysphagia, regurgitation, chest pain and weight loss. The role of inflammatory infiltrates in the pathogenesis of achalasia remains controversial, although the infiltrating cell profile in the tissue has been previously characterized histologically and immunohistochemically. The present study aimed to evaluate the serum levels of 27 protein biomarkers to determine their association with achalasia and the clinical disease characteristics. The cytokine, chemokine and growth factor serum profiles of 68 patients with achalasia and 39 healthy individuals were explored using the 27-Bio-Plex Pro Human Cytokine assay. Reductions in the levels of inflammatory mediators IL-1β, IL-2, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, IL-15, IL-17, fibroblast growth factor, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, interferon-γ, monocyte chemoattractant protein-1, macrophage inflammatory protein-1 (MIP-1)α and MIP-1β, regulated upon activation normal T cell expressed and presumably secreted, TNF-α and VEGF were detected in the serum samples of patients with achalasia compared with those in the control group (P<0.05). However, significant associations between the expression in the levels of inflammatory factors and clinical characteristics of the patients were not found (P>0.05). These results suggest that achalasia is a disease that has a local but not a systemic inflammatory pattern. Further studies are required to improve the current understanding of the mechanism underlying this disease.

Endoscopic Surveillance in Idiopathic Achalasia

Idiopathic achalasia is a rare esophageal dysmotility disorder of unknown etiology with only palliative treatment available. Many studies have established a significantly increased risk of esophageal cancer in patients with achalasia. However, current guidelines advise against routine surveillance due to low absolute risk and a paucity of high-quality evidence and cost-effectiveness assessments. This review aims to assess the need for routine endoscopic surveillance in achalasia based on a growing body of literature calling in support of it, mainly due to the increased risk of esophageal cancer. We searched PubMed and Google Scholar electronic databases for articles within the last 10 years using the keywords 'achalasia', 'cancer,' 'neoplasms,' 'screening,' and 'surveillance.' After excluding pseudoachalasia/secondary achalasia, other esophageal dysmotility disorders, and associations with malignancies outside the esophagus, we selected 31 articles for this review. Through these articles, we identified areas of focus for ongoing and future research that may result in significant risk reduction of complications, including esophageal cancer and beyond.

Identification of differentially expressed microRNAs in primary esophageal achalasia by next-generation sequencing

Molecular knowledge regarding the primary esophageal achalasia is essential for the early diagnosis and treatment of this neurodegenerative motility disorder. Therefore, there is a need to find the main microRNAs (miRNAs) contributing to the mechanisms of achalasia. This study was conducted to determine some patterns of deregulated miRNAs in achalasia. This case-control study was performed on 52 patients with achalasia and 50 nonachalasia controls. The miRNA expression profiling was conducted on the esophageal tissue samples using the next-generation sequencing (NGS). Differential expression of miRNAs was analyzed by the edgeR software. The selected dysregulated miRNAs were additionally confirmed using the quantitative reverse transcription polymerase chain reaction (qRT-PCR). Fifteen miRNAs were identified that were significantly altered in the tissues of the patients with achalasia. Among them, three miRNAs including miR-133a-5p, miR-143-3p, and miR-6507-5p were upregulated. Also, six miRNAs including miR-215-5p, miR-216a-5p, miR-216b-5p, miR-217, miR-7641 and miR-194-5p were downregulated significantly. The predicted targets for the dysregulated miRNAs showed significant disease-associated pathways like neuronal cell apoptosis, neuromuscular balance, nerve growth factor signaling, and immune response regulation. Further analysis using qRT-PCR showed significant down-regulation of hsa-miR-217 (p-value = 0.004) in achalasia tissue. Our results may serve as a basis for more future functional studies to investigate the role of candidate miRNAs in the etiology of achalasia and their application in the diagnosis and probably treatment of the disease.

Multicenter Evaluation with Eckardt Score of Laparoscopic Management with Heller Myotomy and Dor Fundoplication for Esophageal Achalasia in a Pediatric Population in Colombia

Background: Esophageal achalasia is a rare, chronic, and progressive neurodegenerative motility disorder that is characterized by a lack of relaxation of the lower esophageal sphincter. Laparoscopic Heller myotomy (LHM) is the ideal in our population. Multiple surgical and medical treatments have been raised. However, there has been a need to expand studies and generate a clear algorithm for an ideal therapeutic algorithm. Methods: Clinical record was retrospectively analyzed of patients who underwent LHM and Dor fundoplication evaluated with Eckardt score, at four Colombian medical centers between February 2008 and December 2018. Results: There were a total of 21 patients (12 males and 9 females, ages 8 months to 16 years). The time from onset of symptoms to surgery was between 5 months and 14 years. One patient had esophageal mucosa perforation, 2 patients were converted to open surgery, and 1 patient had a postoperative fistula. All patients were discharged 3 to 9 days postoperatively, at which time they tolerated normal oral feeding. During follow-up, all the patients had an improvement in nutritional status and a greater functional recovery; 4 had reflux and 1 had reflux-like symptoms. Conclusion: LHM with Dor-type fundoplication maintains the effectiveness of open surgery with low postoperative morbidity and mortality and good functional results according to Eckardt score evaluation.

Manometric pattern progression in esophageal achalasia in the era of high-resolution manometry

Esophageal manometry represents the gold standard technique for the diagnosis of esophageal achalasia because it can detect both the lack of lower esophageal sphincter (LES) relaxation and abnormal peristalsis. From the manometric standpoint, cases of achalasia can be segregated on the grounds of three clinically relevant patterns according to the Chicago Classification v3.0. It is currently unclear whether they represent distinct entities or are part of a disease continuum with the possibility of transition from a pattern to another one. The four cases described in the present report could provide further insights on this topic because the manometric pattern changed from type III to type II in all patients—without any invasive treatment. The cases described here support the hypothesis that the different manometric patterns of achalasia represent different stages in the evolution of the same disease, type III being the early stage, type II an intermediate stage, and type I probably the end stage of achalasia.

Per oral endoscopic myotomy (POEM) in pediatric patients with esophageal achalasia: First Latin-American experience

BACKGROUND

Achalasia is the most common primary motor disorder of the esophagus, but its incidence in pediatric patients is low. Laparoscopic Heller myotomy (LHM) is the current surgical standard of care treatment. Per-oral endoscopic myotomy (POEM) has emerged as a safe and effective therapeutic alternative in adult patients. We herein report the outcomes of a cohort of pediatric patients with achalasia treated by POEM at a Chilean medical center.

METHODS

This is a retrospective analysis of prospectively collected data on children who underwent POEM for esophageal achalasia. Clinical follow-up was evaluated by recording the Eckardt score, a high-resolution esophageal manometry (HREM) three months after the procedure, and an annual upper gastrointestinal endoscopy.

RESULTS

Five patients with esophageal achalasia confirmed by HREM and with a mean age of 11 (5 to 15) years underwent POEM between 2017 and 2019. One patient had a previous LHM. No morbidity or mortality was observed. All patients resolved their dysphagia and no patient required further interventions. Mean Eckardt score reduced from 10 points preoperatively to 1 point postoperatively. Two patients currently have mild esophagitis (confirmed by endoscopy).

CONCLUSION

Our results support the previously reported safety and effectiveness of POEM. Longer follow-up and larger cohorts will be important to confirm its role in the treatment of children with esophageal achalasia.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Achalasia and esophageal cancer: a large database analysis in Japan

BACKGROUND

Achalasia has been reported to be associated with esophageal cancers (ECs). However, owing to the rarity of achalasia, details of achalasia-related ECs are not well investigated.

METHOD

The incidence of ECs in Japanese patients with achalasia and achalasia-related esophageal motility disorders (EMDs) was estimated, and risk factors for achalasia-related ECs were determined. Characteristics of ECs and treatment courses were also analyzed.

RESULTS

Between 2010 and 2019, 2714 Japanese patients with achalasia and achalasia-related EMDs were recorded in 7 high-volume centers; 24 patients (21 men, 3 women) developed ECs. The incidence of ECs was estimated at 0.078 and 0.28 per 100 person-years from the onset and the diagnosis of disease, respectively. Kaplan-Meier estimate suggested that, in addition to a long history of achalasia, advanced age, male sex, and regular alcohol consumption were statistically significant risk factors for EC development. A prevalence of 40 ECs (12.5% multiple lesions, and 22.7% metachronal lesions) was also noted, predominantly distributed over the thoracic esophagus. All were histologically diagnosed as squamous cell carcinoma. Superficial ECs were successfully treated with endoscopic treatment in all cases, except one. Achalasia-related Barret esophagus was extremely rare, and Barret adenocarcinoma was not detected in our cohort.

CONCLUSION

The high relative risk of ECs was clarified in Japanese achalasia patients, although the absolute risk remained low. Therefore, surveillance endoscopy may be recommended in limited patients with several aforementioned risk factors determined. Superficial cancer can be treated with endoscopic treatment. Multiple and metachronal ECs should be screened.

Achalasia: physiology and diagnosis

Achalasia is a rare motility disorder with incomplete relaxation of the lower esophageal sphincter and ineffective contractions of the esophageal body. It has been hypothesized that achalasia does not result from only one pathway but rather involves a combination of infectious, autoimmune, and familial etiological components. On the basis of other observations, a novel hypothesis suggests that a muscular form of eosinophilic esophagitis is involved in the pathophysiology of achalasia in some patients. This appears to progressively diminish the myenteric plexus at stage III, gradually destroy it at stage II, and finally eliminate it at stage I, the most advanced and final stage of achalasia. Although high-resolution manometry has identified these three different types of achalasia, another subset of patients with a normal-appearing sphincter relaxation has been proposed. Provocative maneuvers, such as the rapid drinking challenge, have recently been demonstrated to improve diagnosis in certain borderline patients, but have to be studied in more detail. However, whether the different types of achalasia will have a long-term impact on tailored therapies is still a matter of debate. Additionally, novel aspects of the standard timed barium swallow appear to be an important adjunct of diagnosis, as it has been shown to have a diagnostic as well as a predictive value.

Endoscopic ultrasound-measured muscular thickness of the lower esophageal sphincter and long-term prognosis after peroral endoscopic myotomy for achalasia

BACKGROUND

People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.

AIM

To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.

METHODS

All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.

RESULTS

Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening (P < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course (P < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; P < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; P < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.

CONCLUSION

Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.

ACG Clinical Guidelines: Diagnosis and Management of Achalasia

Achalasia is an esophageal motility disorder characterized by aberrant peristalsis and insufficient relaxation of the lower esophageal sphincter. Patients most commonly present with dysphagia to solids and liquids, regurgitation, and occasional chest pain with or without weight loss. High-resolution manometry has identified 3 subtypes of achalasia distinguished by pressurization and contraction patterns. Endoscopic findings of retained saliva with puckering of the gastroesophageal junction or esophagram findings of a dilated esophagus with bird beaking are important diagnostic clues. In this American College of Gastroenterology guideline, we used the Grading of Recommendations Assessment, Development and Evaluation process to provide clinical guidance on how best to diagnose and treat patients with achalasia.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation

BACKGROUND

Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients.

METHODS

Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3.

RESULTS

A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups.

CONCLUSIONS

In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Acute Airway Obstruction and Cardiopulmonary Arrest due to Tracheomalacia Caused by Megaesophagus Compression Secondary to Achalasia

We report the case of an 80-year-old woman who presented one episode of cardiopulmonary arrest and two episodes of acute airway obstruction. We found in this patient the presence of tracheomalacia caused by megaesophagus compression secondary to achalasia probably responsible for episodes of acute airway obstruction and cardiopulmonary arrest.

Characteristics of a Subset of Achalasia With Normal Integrated Relaxation Pressure

Background/Aims

Integrated relaxation pressure (IRP) is a critical diagnostic criterion to define achalasia. However, there are some cases with typical symptoms and signs of achalasia but with normal IRP. The aim of this study is to evaluate the clinical characteristics of patients with achalasia with normal IRP and outcomes after peroral endoscopic myotomy (POEM).

Methods

Patients with achalasia were collected in whom POEM was performed from November 2014 to April 2018 at CHA Bundang Medical Center. Achalasia with normal IRP was defined by findings compatible to achalasia in Eckardt score, endoscopy with endoscopic ultrasound, high-resolution manometry, impedance planimetry (EndoFlip), and timed esophagogram.

Results

POEM was performed in 89 patients with achalasia; among them, 24 (27%) patients were diagnosed with achalasia with normal IRP. Patients with achalasia with normal IRP were older, had longer duration of symptom, and had a more tortuous esophagus. In EndoFlip, the distensibility index and cross-sectional area were higher in patients with normal IRP. Therapeutic outcomes showed no statistically significant differences. On correlation analysis, IRP had negative correlations with age, disease duration, and distensibility index.

Conclusions

Patients with achalasia of normal IRP value were older and had longer disease duration and higher distensibility index and cross-sectional area than patients with achalasia with abnormal relaxation of lower esophageal sphincter. Therapeutic outcomes were not different between the 2 groups.