Diaphragmatic hernia after laparoscopic esophagomyotomy for esophageal achalasia in pregnancy

Achalasia During Pregnancy: Proposed Management Algorithm Based on a Thorough Literature Review

Fewer than 40 cases of achalasia occurring in pregnant woman have been reported in the literature. Given the rarity of achalasia during pregnancy, and the numerous treatment options that are available for achalasia in general, no guidelines exist for the management of achalasia during pregnancy. Diagnosis of new cases may be difficult as symptoms and physiological changes that occur during pregnancy may obscure the clinical presentation of achalasia. The management of achalasia in pregnancy is also challenging. Treatment decisions should be individualized for each case, considering both the welfare of the mother and the fetus. Since pregnant women suffering from achalasia represent a diagnostic and therapeutic challenge with complex maternal-fetal aspects to consider, we have reviewed the available literature on the subject and summarized current diagnostic and therapeutic options. Additionally, we present a management algorithm as a means to guide treatment of future cases. We recommend that a conservative approach should be adopted with bridging therapies performed until after delivery when definitive treatment of achalasia can be more safely performed.

Postoperative pregnancy in female achalasia patients: Report of three cases

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The relationship between symptoms recurrence and postoperative pregnancy after surgery in achalasia patients remains unclear.

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This study retrospectively investigated 3 patients who became pregnant after surgery.

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All 3 patients who became pregnant after achalasia surgery had temporary symptom recurrence.

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However, these patients could delivery without any treatment, and their symptoms improved immediately after delivery.

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The pregnancy may have negative impact on temporary symptom and recurrence in achalasia patients after surgery.

Background

The aggravation of symptoms in female patients with esophageal achalasia has been sporadically reported to be associated with pregnancy. However, the relationship between symptoms recurrence and postoperative pregnancy after radical surgery remains unclear.

Case presentation

There were 3 female achalasia patients who became pregnant after surgery between 1994 and 2018. Patient #1, #2 and #3 were 32, 27 and 25 years old, respectively. The main symptom was vomiting in #1, chest pain in #2, dysphagia in #3, the Eckardt score was 12, 9 and 7, respectively. The classification of achalasia was St grade Ⅱ in #1-2, St grade Ⅲ in #3. Laparoscopic Heller-Dor was underwent in all patients, there were no intraoperative and postoperative complications, and the symptoms improved in these patients. The Eckardt scores decreased to 2, 3 and 1, respectively. Each patient became pregnant 36, 24 and 46 months after surgery, and symptoms recurred during pregnancy in all patients. The Eckardt scores increased to 4, 5 and 4. These patients were followed without oral administration due to the risk of teratogenicity, and the pregnancies progressed smoothly. Healthy babies were delivered vaginally at 38–41 weeks. The symptoms in all patients were immediately improved after delivery, and there was no recurrence of symptoms thereafter.

Conclusions

This case report showed that female patients who became pregnant after achalasia surgery had temporary symptom relapse during pregnancy. It was possible to continue pregnancy and deliver without treatment, and symptoms spontaneously improved immediately after delivery.

Esophageal achalasia and pregnancy: own observations in 43 patients and a review of the literature

INTRODUCTION

Little is known concerning the interaction of achalasia and pregnancy and about an optimal time and type for treatment. Achalatic women of our collective of patients with at least one pregnancy in their history resulting in confinement or miscarriage were invited for a structured interview.

MATERIALS AND METHODS

43 of 109 female patients were included. Questionnaire contained questions on symptoms, type of symptoms, whether patients could link a specific event with outbreak of disease. Date of primary diagnosis and individual therapies were double checked against our documentation as well as duration of complaints and kind of therapy. Patients were asked about their obstetric history, whether and how symptoms had changed, and during which pregnancy week symptoms have occurred. Temporal correlation of the diagnosis of achalasia and pregnancy was investigated.

RESULTS

There was no relationship between pregnancy and onset of achalasia. Risk of subfertility, undernourishment, premature birth, or miscarriage does not seem to be increased in achalasia. Health condition often worsened significantly during pregnancy, mainly in the first trimester and particularly in the untreated patients.

CONCLUSIONS

It is advisable to clarify the diagnosis if symptoms suspicious of an achalasia are present before a planned pregnancy. In case of manifest achalasia, surgical treatment should be performed before pregnancy and the improvement in the state of health should be anticipated, as, otherwise, a considerable deterioration of the symptoms during pregnancy may occur. Scientific impact of our observations is very limited and prospective clinical trials are required.

Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series

Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.