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Zanini LYK, Herbella FAM, Velanovich V, Patti MG. Modern insights into the pathophysiology and treatment of pseudoachalasia. Langenbecks Arch Surg 2024; 409:65. [PMID: 38367052 DOI: 10.1007/s00423-024-03259-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Secondary achalasia or pseudoachalasia is a clinical presentation undistinguishable from achalasia in terms of symptoms, manometric, and radiographic findings, but associated with different and identifiable underlying causes. METHODS A literature review was conducted on the PubMed database restricting results to the English language. Key terms used were "achalasia-like" with 63 results, "secondary achalasia" with 69 results, and "pseudoachalasia" with 141 results. References of the retrieved papers were also manually reviewed. RESULTS Etiology, diagnosis, and treatment were reviewed. CONCLUSIONS Pseudoachalasia is a rare disease. Most available evidence regarding this condition is based on case reports or small retrospective series. There are different causes but all culminating in outflow obstruction. Clinical presentation and image and functional tests overlap with primary achalasia or are inaccurate, thus the identification of secondary achalasia can be delayed. Inadequate diagnosis leads to futile therapies and could worsen prognosis, especially in neoplastic disease. Routine screening is not justifiable; good clinical judgment still remains the best tool. Therapy should be aimed at etiology. Even though Heller's myotomy brings the best results in non-malignant cases, good clinical judgment still remains the best tool as well.
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Affiliation(s)
- Leonardo Yuri Kasputis Zanini
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, São Paulo, 04037-003, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 Cj 301, São Paulo, 04037-003, Brazil.
| | - Vic Velanovich
- Department of Surgery, University of South Florida, Tampa, USA
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, USA
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Kouzmina E, Bechara R, Zevin B. Resection of Fibrous Pseudocapsule in a Patient with Secondary Achalasia and Persistent Symptoms After Removal of Adjustable Gastric Band: Case Report and Review of the Literature. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2021.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Robert Bechara
- Department of Medicine, Queen's University, Kingston, Canada
| | - Boris Zevin
- Department of Surgery, Queen's University, Kingston, Canada
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Haj Ali SN, Nguyen NQ, Abu Sneineh AT. Pseudoachalasia: a diagnostic challenge. When to consider and how to manage? Scand J Gastroenterol 2021; 56:747-752. [PMID: 34043926 DOI: 10.1080/00365521.2021.1925957] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pseudoachalasia accounts for up to 4% of patients who present with achalasia-like picture and most often relates to occult malignancy at the cardia or gastroesophageal junction. Thus, any delay in diagnosis might lead to more advanced disease and less chance for curative therapy, not to mention the risk of serious complications resulting from the treatment of supposed achalasia instead of the true underlying cause. The entity should be suspected in patients with advanced age of onset, a shorter duration of symptoms, profound weight loss and difficulty in passing the gastroesophageal junction on endoscopy. The diagnosis of pseudoachalasia can be challenging as upper endoscopy with biopsy might be false negative in 25% of cases and lesions cannot always be detected on computerized tomography scan. Endoscopic ultrasound and guided biopsy play an increasingly important role in the workup of this condition. Treatment of pseudoachalasia depends on the underlying cause. The aim of this review is to highlight the clinicopathological features that distinguish pseudoachalasia from achalasia and the most appropriate diagnostic workup as well as the subsequent management for this condition.
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Affiliation(s)
- Sara N Haj Ali
- Department of Internal Medicine, Faculty of Medicine, Al-Balqa Applied University, Salt, Jordan
| | - Nam Q Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Awni T Abu Sneineh
- Department of Gastroenterology, Jordan University Hospital, Amman, Jordan
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Crafts TD, Lyo V, Rajdev P, Wood SG. Treatment of achalasia in the bariatric surgery population: a systematic review and single-institution experience. Surg Endosc 2020; 35:5203-5216. [PMID: 33048227 DOI: 10.1007/s00464-020-08015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 09/16/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5-1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain. METHODS Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response. RESULTS Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy. CONCLUSIONS Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.
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Affiliation(s)
- Trevor D Crafts
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L223A, Portland, OR, 97239, USA
| | - Victoria Lyo
- Department of Surgery, University of California Davis, 2335 Stockton Blvd., #6113, Sacramento, CA, 95817, USA
| | - Priya Rajdev
- Department of General Surgery, University of Arizona College of Medicine, Phoenix, AZ, 85004, USA
| | - Stephanie G Wood
- Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Code: L223A, Portland, OR, 97239, USA.
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Schizas D, Theochari NA, Katsaros I, Mylonas KS, Triantafyllou T, Michalinos A, Kamberoglou D, Tsekrekos A, Rouvelas I. Pseudoachalasia: a systematic review of the literature. Esophagus 2020; 17:216-222. [PMID: 31989338 DOI: 10.1007/s10388-020-00720-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/20/2020] [Indexed: 02/03/2023]
Abstract
Pseudoachalasia, also known as secondary achalasia, is a clinical condition mimicking idiopathic achalasia but most commonly caused by malignant tumors of gastroesophageal junction (GEJ). Our aim was to systematically review and present all available data on demographics, clinical features, and diagnostic modalities involved in patients with pseudoachalasia. A systematic search of literature published during the period 1978-2019 was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end-of-search date: June 25th, 2019). Two independent reviewers extracted data with regards of study design, interventions, participants, and outcomes. Thirty-five studies met our inclusion criteria and were selected in the present review. Overall, 140 patients with pseudoachalasia were identified, of whom 83 were males. Mean patient age was 60.13 years and the mean weight loss was 13.91 kg. A total of 33 (23.6%) patients were wrongly 'treated' at first for achalasia. The most common presenting symptoms were dysphagia, food regurgitation, and weight loss. The median time from symptoms' onset to hospital admission was 5 months. Most common etiology was gastric cancer (19%). Diagnostic modalities included manometry, barium esophagram, endoscopy, and computed tomography (CT). Pseudoachalasia is a serious medical condition that is difficult to be distinguished from primary achalasia. Clinical feature assessment along with the correct interpretation of diagnostic tests is nowadays essential steps to differentiate pseudoachalasia from idiopathic achalasia.
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Affiliation(s)
- Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Nikoletta A Theochari
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece.
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Konstantinos S Mylonas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, 29 Parnithos, 16344, Ilioupolis, Athens, Greece
| | - Tania Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | | | - Dimitrios Kamberoglou
- Department of Gastroenterology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Andrianos Tsekrekos
- Division of Surgery, Department of Clinical Science Intervention and Technology, Department of Upper Abdominal Diseases, Karolinska Institutet, Stockholm, Sweden
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Department of Upper Abdominal Diseases, Karolinska Institutet, Stockholm, Sweden
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Rayman S, Goldenshluger M, Goitein O, Dux J, Sakran N, Raziel A, Goitein D. Conversion for failed adjustable gastric banding warrants hiatal scrutiny for hiatal hernia. Surg Endosc 2018; 33:2231-2234. [PMID: 30341651 DOI: 10.1007/s00464-018-6509-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Failure or complications following laparoscopic adjustable gastric banding (LAGB) may necessitate band removal and conversional surgery. Band position and band-induced chronic vomiting create ideal conditions for de novo hiatal hernia (HH) formation. HH presence impedes and complicates conversional surgery by obscuring crucial anatomical landmarks and hindering precise gastric sleeve or pouch formation. The aim of this study was to evaluate the incidence of a HH in patients with an LAGB undergoing conversion compared to patients undergoing primary bariatric surgery (BS). METHODS Retrospective review of consecutive BS performed between 2010 and 2015. Data collected included demographics, anthropometrics, comorbidities, previous BS, preoperative and intra-operative HH detection, operation time, perioperative complications and length of hospital stay. RESULTS During the study period, 2843 patients (36% males) underwent BS. Of these, 2615 patients (92%) were "primary" (no previous BS-control group), 197 (7%) had a previous LAGB (study group), and 31 (1%) had a different previous BS and were excluded. Reasons for conversion included weight regain, band intolerance and band-related complications. Mean age and body mass index were similar between the study and the control groups. HH was preoperatively diagnosed by upper gastrointestinal (UGI) fluoroscopy in 9.1% and 9.0% of the LAGB and control groups (p = NS), respectively. However, HH was detected intra-operatively in 20.3% and 7.3%, respectively (p < 0.0001). CONCLUSIONS Preoperative diagnosis of a HH by UGI fluoroscopy for patients who have undergone LAGB is unreliable. Intra-operative hiatal exploration is highly recommended in all cases of conversional BS after LAGB.
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Affiliation(s)
- Shlomi Rayman
- Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Goldenshluger
- Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Goitein
- Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joseph Dux
- Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nasser Sakran
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
- Department of Surgery A, Emek Medical Center, Afula, Israel
- Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Asnat Raziel
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - David Goitein
- Department of Surgery C, Chaim Sheba Medical Center, Tel Hashomer, Israel.
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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