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Fukushima N, Masuda T, Tsuboi K, Hoshino M, Takahashi K, Yuda M, Sakashita Y, Takeuchi H, Omura N, Yano F, Eto K. Role of modified Glasgow Prognostic Score in patients with achalasia who underwent laparoscopic Heller-myotomy with Dor-fundoplication. Esophagus 2024; 21:374-382. [PMID: 38431541 DOI: 10.1007/s10388-024-01047-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Systemic inflammatory response is significant prognostic indicator in patients with various diseases. The relationship between prognostic scoring systems based on the modified Glasgow Prognostic Score (mGPS) and achalasia in patients treated with laparoscopic Heller‑myotomy with Dor‑fundoplication (LHD) remains uninvestigated. This study aimed to examine the role of mGPS in patients with achalasia. METHODS 457 patients with achalasia who underwent LHD as the primary surgery between September 2005 and December 2020 were included. We divided patients into the mGPS 0 and mGPS 1 or 2 groups and compared the patients' background, pathophysiology, symptoms, surgical outcomes, and postoperative course. RESULTS mGPS was 0 in 379 patients and 1 or 2 in 78 patients. Preoperative vomiting and pneumonia were more common in patients with mGPS of 1 or 2. There were no differences in surgical outcomes. Postoperative upper gastrointestinal endoscopy revealed that severe esophagitis was more frequently observed in patients with mGPS of 1 or 2 (P < 0.01). The clinical success was 91% and 99% in the mGPS 0 and mGPS 1 or 2 groups, respectively (P < 0.01). CONCLUSIONS Although severe reflux esophagitis was more common in patients with achalasia with a high mGPS, good clinical success was obtained regardless of the preoperative mGPS.
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Affiliation(s)
- Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Kazuto Tsuboi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Keita Takahashi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masami Yuda
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hideyuki Takeuchi
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Nobuo Omura
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ken Eto
- Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishishinbashi, Minato-Ku, Tokyo, 105-8461, Japan
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Abu Suleiman A, James D, Wilkins A, Bladel AV, Lo T. Achalasia-associated megaoesophagus presenting with dyspnoea and cough. BMJ Case Rep 2024; 17:e258950. [PMID: 38367990 PMCID: PMC10875499 DOI: 10.1136/bcr-2023-258950] [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] [Indexed: 02/19/2024] Open
Abstract
We present an unusual case of achalasia presenting with dyspnoea and persistent cough. These symptoms persisted for months, leading to the patient undergoing a chest X-ray by her general practitioner which showed right basal consolidation and a density extending along the right mediastinum. CT scan was done which revealed megaoesophagus with a diameter of 7 cm causing tracheal compression, as well as right basal consolidation, consistent with aspiration. Further history revealed 6-month history of progressive swallowing difficulty, retrosternal chest pain and shortness of breath which worsened when eating solid foods. After thorough workup, a diagnosis of idiopathic achalasia (type II) was made. She was treated with laparoscopic Heller cardiomyotomy and Dor fundoplication with significant improvement at follow-up. Dyspnoea and respiratory symptoms are unusual presenting symptoms, suggesting a need to consider achalasia in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis and intervention prior to oesophageal failure.
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Affiliation(s)
- Amro Abu Suleiman
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Daniel James
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Alexander Wilkins
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
| | - Adrian Van Bladel
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Terence Lo
- Department of Upper Gastrointestinal Surgery, Hull University Teaching Hospitals NHS Trust, Cottingham, UK
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Nakajima M, Masuda N, Shoda T, Wakayama S, Kono T, Ogawa A, Takita J, Haga N, Suzuki K, Yamaguchi S, Nakamura T, Kojima K. Laparoscopic Heller myotomy with Dor fundoplication for esophageal achalasia treatment after distal gastrectomy and Billroth-II reconstruction. Asian J Endosc Surg 2023. [PMID: 37308447 DOI: 10.1111/ases.13215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/25/2023] [Indexed: 06/14/2023]
Abstract
Laparoscopic Heller myotomy with Dor fundoplication is the standard surgical treatment for esophageal achalasia. However, there are few reports on the use of this method after gastric surgery. We report a case of a 78-year-old man who underwent laparoscopic Heller myotomy with Dor fundoplication for achalasia after distal gastrectomy and Billroth-II reconstruction. After the intraabdominal adhesion was sharply dissected using an ultrasonic coagulation incision device (UCID), Heller myotomy was performed 5 cm above and 2 cm below the esophagogastric junction using the UCID. To prevent postoperative gastroesophageal reflux (GER), Dor fundoplication was performed without cutting the short gastric artery and vein. The postoperative course was uneventful, and the patient is in good health without symptoms of dysphagia or GER. Although per-oral endoscopic myotomy is becoming the mainstay of treatment for achalasia after gastric surgery, laparoscopic Heller myotomy with Dor fundoplication is also an effective strategy.
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Affiliation(s)
- Masanobu Nakajima
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Norihiro Masuda
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Takahiro Shoda
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Shigeyoshi Wakayama
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Takahiro Kono
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Atsushi Ogawa
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | - Junko Takita
- Department of Surgery, National Hospital Organization Utsunomiya Hospital, Tochigi, Japan
| | | | - Kan Suzuki
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
| | - Satoru Yamaguchi
- Department of Surgery, Dokkyo Medical University Nikko Medical Center, Tochigi, Japan
| | - Takatoshi Nakamura
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
| | - Kazuyuki Kojima
- Department of Upper Gastrointestinal Surgery, Dokkyo Medical University, Tochigi, Japan
- Department of Surgical Oncology, Dokkyo Medical University Graduate School of Medicine, Tochigi, Japan
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Tsuboi K, Yano F, Omura N, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Sakashita Y, Fukushima N, Ikegami T. Is an objective evaluation essential for determining the therapeutic effect of laparoscopic surgery among patients with esophageal achalasia? Surg Endosc 2022; 36:3932-3939. [PMID: 34494151 DOI: 10.1007/s00464-021-08712-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite a high degree of satisfaction with laparoscopic Heller-Dor surgery (LHD) for esophageal achalasia, some cases show no improvement in postoperative esophageal clearance. We investigated whether an objective evaluation is essential for determining the therapeutic effect of LHD. METHODS We investigated the difference in symptoms, regarding esophageal clearance, using timed barium esophagogram (TBE), in 306 esophageal achalasia patients with high postoperative satisfaction who underwent LHD. Furthermore, these patients were divided into two groups, in accordance with the difference in postoperative esophageal clearance, in order to compare the preoperative pathophysiology, symptoms, and surgical results. RESULTS Although the poor postoperative esophageal clearance group (117 cases, 38%) was mostly male and the ratio of Sigmoid type was high compared to the good postoperative esophageal clearance group (p = 0.046, p = 0.001, respectively); in patients with high surgical satisfaction, there was no difference in terms of preoperative symptom scores and surgical results. However, although the satisfaction level was high in the poor esophageal clearance group, the scores in terms of the postoperative dysphagia and vomiting were high (p = 0.0018 and p = 0.004, respectively). The AUC was 0.9842 upon ROC analysis regarding the presence or absence of clearance at 2 min following postoperative TBE and the postoperative feeling of difficulty swallowing score, with a cut-off value of 2 points (sensitivity: 88%, specificity: 100%) in cases with a high degree of surgical satisfaction. CONCLUSION The esophageal clearance ability can be predicted by subjective evaluation, based on the postoperative symptom scores; so, an objective evaluation is not essential in cases with high surgical satisfaction.
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Affiliation(s)
- Kazuto Tsuboi
- Department of Surgery, Fuji City General Hospital, 50 Takashima-cho, Fuji, Shizuoka, 416-0951, Japan. .,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
| | - Fumiaki Yano
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Omura
- Department of Surgery, Nishisaitama-Chuo National Hospital, Tokorozawa, Saitama, Japan.,Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Masato Hoshino
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Se-Ryung Yamamoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Shunsuke Akimoto
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Sakashita
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Naoko Fukushima
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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A case of esophageal achalasia presenting with empyema and septic shock differentiated from esophageal rupture. Clin J Gastroenterol 2021; 14:422-426. [PMID: 33527334 DOI: 10.1007/s12328-021-01349-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
The patient was a 44-year-old man with a history of schizophrenia. He had a history of esophageal dysphagia and vomiting and presented with sudden strong epigastric pain. He was taken to a medical emergency center in a state of septic shock. Computed tomography revealed a left thoracic abscess, and esophageal rupture was suspected. He was referred to our department for treatment. Gastrointestinal series and gastrointestinal endoscopy revealed marked esophageal dilation and strong contraction of the lower esophageal sphincter. We, therefore, diagnosed the patient with empyema thoracis secondary to aspiration pneumonia due to esophageal achalasia. Conservative treatment with antibiotics and computed tomography-guided chest drainage was initiated, but the inflammation persisted. Thus, we successfully performed a per-oral endoscopic myotomy to manage achalasia symptoms.
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6
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Chang J, Yoo IK, Günay S, Paköz ZB, Cho JY. Clinical usefulness of esophagogastric junction distensibility measurement in patients with achalasia before and after peroral endoscopic myotomy. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:362-367. [PMID: 32519955 DOI: 10.5152/tjg.2020.19105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS This study aimed to determine the clinical efficacy of measuring the esophagogastric junction (EGJ) distensibility index (DI) in patients with achalasia before and after peroral endoscopic myotomy (POEM). MATERIALS AND METHODS Retrospective data were collected from 195 patients who underwent POEM from November 2014 to November 2017 at our clinic. The Eckardt score, high-resolution manometry, and EGJ distensibility were measured before and six months after POEM. Treatment failure was defined as a postprocedure Eckardt score >3 or patients who underwent repeat POEM. RESULTS The DI (mm2/mmHg) before and after POEM was 3.42±3.55 and 11.57±6.64, respectively (p<0.01). There was no difference in the DI between achalasia subtypes I, II, and III (11.45±6.24 versus 15.49±11.53 versus 13.27±9.49, p=0.22) or previous treatment history (15.39±10.85 versus 11.10±7.25, p=0.20). The DI was higher in patients with reflux esophagitis after POEM, but the difference was not significant (13.59±7.15 versus 12.54±10.9, p=0.571). CONCLUSION This study showed that EGJ distensibility measurement is useful to assess post-POEM outcomes. These findings suggest that the functional lumen imaging probe may be a useful method for assessing clinical efficacy of POEM in patients with achalasia. However, this is a costly procedure that requires experience.
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Affiliation(s)
- Junsu Chang
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - In Kyung Yoo
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Süleyman Günay
- Department of Gastroenterology, İzmir Tepecik Education and Research Hospital, İzmir, Turkey
| | - Zehra Betül Paköz
- Department of Gastroenterology, İzmir Tepecik Education and Research Hospital, İzmir, Turkey
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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7
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Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus 2016; 29:807-819. [PMID: 26175119 DOI: 10.1111/dote.12387] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo-peritoneum (30.6%), capno/pneumo-thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post-POEM, respectively. Symptom improvement was demonstrated with a pre- and post-POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre- and post-POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14-16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.
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Affiliation(s)
- K Patel
- Department of Upper Gastro-Intestinal Surgery, East Surrey Hospital, Redhill, UK
| | - N Abbassi-Ghadi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Markar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Kumar
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P Jethwa
- Department of Upper Gastro-Intestinal Surgery, East Surrey Hospital, Redhill, UK
| | - G Zaninotto
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Zhang Y, Wang H, Chen X, Liu L, Wang H, Liu B, Guo J, Jia H. Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Nonrandomized Comparative Studies. Medicine (Baltimore) 2016; 95:e2736. [PMID: 26871816 PMCID: PMC4753912 DOI: 10.1097/md.0000000000002736] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
We aimed to assess the short-term outcomes of per-oral endoscopic myotomy (POEM) compared with laparoscopic Heller myotomy (LHM) for achalasia through a meta-analysis of nonrandomized comparative studies.We searched PubMed, Embase, Medline, Cochrane Library, and Google Scholar for studies that compared POEM and LHM for achalasia and were published between January 1, 2008 and December 31, 2014. The Methodological Index for Nonrandomized Studies (MINORS) was used to evaluate the quality of the studies. Random- and fixed-effects meta-analytical models were used, and between-study heterogeneity was assessed.Four nonrandomized comparative studies that included 317 patients (125 in the POEM group and 192 in the LHM group) met our research criteria and were assessed. There were no differences between the POEM and LHM groups in terms of sex, preoperative Eckhart score, length of myotomy, operation time, length of hospital stay, and complications. The patients in the POEM group were older than those in the LHM group (MD =2.81, 95% CI 0.27-5.35; P = 0.03) with high between-study homogeneity (χ = 1.96, df = 2, I = 0%; P = 0.38). The patients in the POEM group had a lower Eckardt score after surgery compared with those in the LHM group (MD = -0.30, 95% CI -0.42 to -0.18; P < 0.001) with high between-study homogeneity (χ = 0.00, df = 1, I = 0%; P = 1.00).The efficacy and safety of POEM appear to be comparable to those of LHM. Multicenter and randomized trials with larger sample size are needed to further compare the efficacy and safety of POEM and LHM for the treatment of achalasia.
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Affiliation(s)
- Yuan Zhang
- From the Center of Evidence-Based Medicine (YZ, HJ); Department of Gastroenterology, Second Hospital of Shandong University, Jinan, China (HW, LL, HW, BL, JG); and Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (XC)
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Nassri A, Ramzan Z. Pharmacotherapy for the management of achalasia: Current status, challenges and future directions. World J Gastrointest Pharmacol Ther 2015; 6:145-55. [PMID: 26558149 PMCID: PMC4635155 DOI: 10.4292/wjgpt.v6.i4.145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/06/2015] [Accepted: 10/16/2015] [Indexed: 02/06/2023] Open
Abstract
This article reviews currently available pharmacological options available for the treatment of achalasia, with a special focus on the role of botulinum toxin (BT) injection due to its superior therapeutic effect and side effect profile. The discussion on BT includes the role of different BT serotypes, better pharmacological formulations, improved BT injection techniques, the use of sprouting inhibitors, designer recombinant BT formulations and alternative substances used in endoscopic injections. The large body of ongoing research into achalasia and BT may provide a stronger role for BT injection as a form of minimally invasive, cost effective and efficacious form of therapy for patients with achalasia. The article also explores current issues and future research avenues that may prove beneficial in improving the efficacy of pharmacological treatment approaches in patients with achalasia.
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10
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Tsuboi K, Omura N, Yano F, Hoshino M, Yamamoto SR, Akimoto S, Masuda T, Kashiwagi H, Yanaga K. Data analyses and perspectives on laparoscopic surgery for esophageal achalasia. World J Gastroenterol 2015; 21:10830-10839. [PMID: 26478674 PMCID: PMC4600584 DOI: 10.3748/wjg.v21.i38.10830] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 05/29/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
In general, the treatment methods for esophageal achalasia are largely classified into four groups, including drug therapy using nitrite or a calcium channel blocker, botulinum toxin injection, endoscopic therapy such as endoscopic balloon dilation, and surgery. Various studies have suggested that the most effective treatment of esophageal achalasia is surgical therapy. The basic concept of this surgical therapy has not changed since Heller proposed esophageal myotomy for the purpose of resolution of lower esophageal obstruction for the first time in 1913, but the most common approach has changed from open-chest surgery to laparoscopic surgery. Currently, the laparoscopic surgery has been the procedure of choice for the treatment of esophageal achalasia. During the process of the transition from open-chest surgery to laparotomy, to thoracoscopic surgery, and to laparoscopic surgery, the necessity of combining antireflux surgery has been recognized. There is some debate as to which type of antireflux surgery should be selected. The Toupet fundoplication may be the most effective in prevention of postoperative antireflux, but many medical institutions have selected the Dor fundoplication which covers the mucosal surface exposed by myotomy. Recently, a new endoscopic approach, peroral endoscopic myotomy (POEM), has received attention. Future studies should examine the long-term outcomes and whether POEM becomes the gold standard for the treatment of esophageal achalasia.
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11
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Molena D, Mungo B, Stem M, Lidor AO. Hospitalization for esophageal achalasia in the United States. World J Gastrointest Endosc 2015; 7:1096-1102. [PMID: 26421106 PMCID: PMC4580951 DOI: 10.4253/wjge.v7.i13.1096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/02/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the outcome of different treatments in patients admitted for esophageal achalasia in the United States.
METHODS: This is a retrospective analysis using the Nationwide Inpatient Sample over an 8-year period (2003-2010). Patients admitted with a primary diagnosis of achalasia were divided into 3 groups based on their treatment: (1) Group 1: patients who underwent Heller myotomy during their hospital stay; (2) Group 2: patients who underwent esophagectomy; and (3) Group 3: patients not undergoing surgical treatment. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), discharge destination and total hospital charges.
RESULTS: Among 27141 patients admitted with achalasia, nearly half (48.5%) underwent Heller myotomy, 2.5% underwent esophagectomy and 49.0% had endoscopic or other treatment. Patients in group 1 were younger, healthier, and had the lowest mortality when compared with the other two groups. Group 2 had the highest LOS and hospital charges among all groups. Group 3 had the highest mortality (1.2%, P < 0.001) and the lowest home discharge rate (78.8%) when compared to the other groups. The most frequently performed procedures among group 3 were esophageal dilatation (25.9%) and injection (13.3%). Among patients who died in this group the most common associated morbidities included acute respiratory failure, sepsis and aspiration pneumonia.
CONCLUSION: Surgery for achalasia carries exceedingly low mortality in the modern era; however, in complicated patients, even less invasive treatments are burdened by significant mortality and morbidity.
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12
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Kaths JM, Foltys DB, Scheuermann U, Strempel M, Niebisch S, Ebert M, Jansen-Winkeln B, Gockel I, Lang H. Achalasia with megaesophagus and tracheal compression in a young patient: A case report. Int J Surg Case Rep 2015. [PMID: 26209755 PMCID: PMC4573207 DOI: 10.1016/j.ijscr.2015.06.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
This report emphasizes that physicians should be alert and consider airway obstruction and signs of dyspnea as severe and threatening symptoms in extensive cases of achalasia with megaesophagus. Early surgical treatment provides a therapeutic option to obviate the occurrence of acute respiratory distress and consecutive complications. In particular, difficulties in intubation prior to surgery must be considered. Due to potential tracheomalacia, the status of “bull frog neck” in achalasia, including severe tracheal compression caused by megaesophagus with concomitant cervical swelling, may also lead to extubation problems and deserves special care in the postoperative period.
Introduction Achalasia is one of the most common causes of dysphagia. Typical symptoms include difficulties in controlling the swallowing process, regurgitation, weight loss, and chest pain. A megaesophagus rarely causes tracheal compression with consecutive acute dyspnea or similar respiratory symptoms. Presentation of case A 23-year-old male patient presented with difficulties in swallowing, a consecutive massive weight loss over the past three years, and minor respiratory ailments. Further diagnostics revealed a megaesophagus caused by achalasia leading to a severe compression of the trachea. A laparoscopic Heller myotomy with anterior semi-fundoplication 180° according to Dor was performed. Discussion Acute dyspnea and similar respiratory symptoms are rarely observed in patients with achalasia, especially in young patients. Early diagnosis and timely, proper treatment are the hallmarks of restoring esophageal and tracheobronchial function and of successful prevention of severe long-lasting complications of the disease. When not treated properly, the disease may have progressed rapidly, leading to distinct respiratory symptoms such as stridor and acute dyspnea Conclusion This report emphasizes that physicians should be alert and consider airway obstruction and signs of dyspnea as severe and threatening symptoms in extensive cases of achalasia with megaesophagus. Early surgical treatment provides a therapeutic option to obviate the occurrence of acute respiratory distress and consecutive complications. In particular, difficulties in intubation prior to surgery must be considered.
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Affiliation(s)
- J Moritz Kaths
- Department of General-, Visceral- and Transplant Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
| | - Daniel B Foltys
- Department of General-, Visceral- and Transplant Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Uwe Scheuermann
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Germany
| | - Mari Strempel
- Deutsche Stiftung Organtransplantation, Region Mitte, Frankfurt, Germany
| | - Stefan Niebisch
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Germany
| | - Maren Ebert
- Department of Diagnostic and Interventional Radiology, University Medical Centre, Johannes Gutenberg-University Mainz, Germany
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital of Leipzig, Germany
| | - Hauke Lang
- Department of General-, Visceral- and Transplant Surgery, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
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Zhu SB, Zhu J, Yan M, Liu Y. A typical megaesophagus: interesting imaging for diagnosis. Chin Med J (Engl) 2015; 128:1418. [PMID: 25963368 PMCID: PMC4830327 DOI: 10.4103/0366-6999.156817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Shui-Bo Zhu
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei 430070, China
| | - Jian Zhu
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei 430070, China
| | - Ming Yan
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei 430070, China
| | - Yong Liu
- Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei 430070, China
- Address for correspondence: Dr. Yong Liu, Department of Thoracic Cardiovascular Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan, Hubei 430070, China E-Mail:
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Affiliation(s)
- Nelson Adami Andreoll
- Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SAo Paulo, Brazil
| | - Luiz Roberto Lope
- Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SAo Paulo, Brazil
| | - Osvaldo Malafai
- Faculdade Evangelica do Parana, Universidade Federal do Parana, Brazil
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Abstract
PURPOSE OF REVIEW Botulinum toxin injection into the lower esophageal sphincter is an established therapy for the treatment of achalasia. This review will highlight recent studies that shed light on the role of Botulinum toxin injection in the management of achalasia. RECENT FINDINGS Recent studies have shown that Botulinum toxin injection is the most common initial endoscopic therapy for achalasia, most likely due to its safety and ease of administration. However, this trend represents a deviation from recent guidelines which consider Botulinum toxin injection less efficacious than alternative treatments like pneumatic dilation and laparoscopic Heller myotomy. Over the past decade, multiple commercial formulations of Botulinum toxin injection have been introduced, but the techniques, indications, and therapeutic efficacy for Botulinum toxin have largely remained unchanged. This review will evaluate recent guidelines, consensus articles, meta-analyses, and landmark studies to expound on the short and long-term efficacy of Botulinum toxin, injection dosages, and technique, as well as its efficacy compared to pneumatic dilation, myotomy, and combination therapy. SUMMARY Despite its relatively poor long-term efficacy, Botulinum toxin injection continues to play an important role in elderly patients with comorbidities and as salvage therapy for achalasia.
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