Clinical management of achalasia: current state of the art

Challenges in Diagnosis and Treatment of Achalasia Cardia in Uganda: A Case Report of an Adolescent Female Presenting With Dysphagia

Background: Our case highlights the challenges in diagnosing and managing achalasia cardia, particularly in resource-limited settings and more so in adolescents who fall outside of the typical age range. Case Presentation: We present a case of an 18-year-old female from Uganda who was admitted with a 6-month history of progressive dysphagia, weight loss, and postprandial vomiting. Diagnosis of achalasia cardia was confirmed via endoscopy and barium swallow. Heller cardiomyotomy via open transthoracic approach was performed, but she developed an esophageal perforation, which was successfully managed with repeat thoracotomy and esophageal repair. Complete resolution of achalasia symptoms was achieved at a 5-month follow-up. Conclusion: This case highlights the importance of maintaining a high index of clinical suspicion, especially in young patients, and the significance of informed consent prior to initiating treatment. Additionally, it emphasizes the importance of early recognition of treatment-related complications, such as esophageal perforation, as key to prompt management and improved patient outcomes.

Relationship Between Lower Esophageal Sphincter Muscles Thickness and Their Response to Pneumatic Dilation in Patients With Achalasia

Background

Prognostic factors play a major role in managing achalasia patients treated with pneumatic dilatation (PD) and understanding the pathophysiology of the disease. In this regard, the muscular thickness of the lower esophageal sphincter (LES) has drawn attention in recently published studies.

Methods

Patients with newly diagnosed achalasia were included consecutively in this study, and Endoscopic Ultrasound (EUS) was used to determine the thickness of longitudinal and circular muscles of LES. To determine the recurrence of symptoms, patients were followed up for one year using the Eckardt questionnaire. The relationship between pre-treatment LES muscle thickness and symptom recurrence was investigated.

Results

Seventeen of nineteen treated patients were enrolled in this study and the data of sixteen patients was analyzed. Although not statistically significant, those with thinner LES had recurrent symptoms ( p-value = 0.08). Patients with a thicker LES (5.1 mm vs. 4.6 mm) initially responded better to pneumatic dilatation ( p-value = 0.03). After initial therapy, severe pain (daily pain) was strongly associated with symptom recurrence.

Conclusions

Severe retrosternal chest pain and a thin LES appear to be surrogate markers for advanced disease and poor outcomes. Pre-treatment integrated relaxation pressure (IRP) seems to be a promising predictor of PD prognosis. Due to the study's heterogeneous population, the findings cannot be generalized to all achalasia patients, and larger-scale studies are necessary to confirm these findings.

[Features and results of minimally invasive treatment of recurrent achalasia]

OBJECTIVE

To evaluate the early and long-term postoperative outcomes in patients with recurrent achalasia, as well as the main features of surgical treatment.

MATERIAL AND METHODS

There were 7 patients (4 men and 3 women) with recurrent achalasia. Mean age of patients was 42.3±13.5 years, body mass index - 22.7±3.3 kg/m². Physiological status ASA grade 1-3 was observed in all patients. Concomitant diseases were diagnosed in 5 (71.4%) cases. Six (85.7%) patients underwent laparoscopic Heller cardiomyotomy with Dor fundoplication. Peroral endoscopic myotomy (POEM) was performed in 1 (14.3%) patient. Mean preoperative Eckardt score was 10.7±1.4 points, mean GERD-HRQL score - 42.7±6.4 points. According to preoperative radiography, 5 (71.4%) patients had achalasia stage III, 2 (28.6%) ones - stage IV.

RESULTS

All patients underwent laparoscopic Heller esophagocardiomyotomy with anterior Dor fundoplication and posterior partial fundoplication with posterior cruroraphy. Intraoperative complications (perforation of esophageal mucosa) occurred in 3 (42.9%) patients. Mean surgery time was 130±56 min, mean blood loss - 37 ml (35-205 ml), mean hospital-stay - 11.3±7.7 days. Postoperative complications Clavien-Dindo grade 3-4 were detected in 1 (14.3%) patient. One patient was diagnosed with bilateral pneumonia (SARS-Cov-2 infection) in 4 postoperative days. Median postoperative follow-up period was 22 months. Mean BMI in 6 months after surgery was 25.3±3.1 kg/m², mean Eckardt score - 2.1±0.7 points, mean GERD-HRQL score - 3.3±0.9 points.

CONCLUSION

Our data confirm the effectiveness and safety of the modified laparoscopic Heller procedure with Dor fundoplication as the main method for recurrent achalasia.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery

Introduction:

We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function.

Patients and Methods:

Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated.

Results:

No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux.

Conclusions:

The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

Achalasia is associated with a higher incidence of depression in outpatients in Germany

Background and aim

Achalasia represents a chronic motility disorder of the esophagus featuring an impaired lower esophageal sphincter relaxation and loss of esophageal peristalsis. By causing dysphagia, regurgitation, aspiration and chest pain, achalasia might tremendously affect life quality of patients. However, the impact of achalasia on the development of mood disorders including depression has largely remained unclear. The aim of this study was to evaluate the incidence of depression in achalasia patients.

Methods

We analyzed a large primary care cohort database in Germany capturing data from 7.49 million patients.

Results

A total of n = 1,057 patients with achalasia diagnosed between January 2005 and December 2018 were matched to a cohort of n = 3,171 patients without achalasia controlling for age, sex, physician, index year, and the Charlson comorbidity index. Interestingly, while the frequency of depression prior to the diagnosis of achalasia was comparable in both groups, new diagnoses of depression were significantly higher within one year after the diagnosis of achalasia compared to the control group, suggesting a direct and previously unrecognized association between achalasia and depression.

Conclusion

Our data suggest that the clinical management of patients with achalasia should include a careful and structured work-up for mood disorders in order to improve long-term quality of life in these patients.

Lung Nodule and Food Bolus Impaction: Can They Be Related?

Achalasia is a rare primary disorder of esophageal motility characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patient complaints of dysphagia to solids and liquids, regurgitation, chest pain, and weight loss. However, achalasia may also present with respiratory symptoms, such as aspiration pneumonia, due to remarkable regurgitation. In untreated patients and a long period of evolution, respiratory symptoms may even be the initial manifestation of achalasia. An endoscopic finding of retained food and saliva with a puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. We describe an atypical presentation of a rare disease in a young man with a history of symptoms caused by the late manifestation of achalasia.

ACHALASIA: DIAGNOSTIC FEATURES AND EFFECTIVE TREATMENT METHODS. REVIEW

Еsophageal achalasia is a neuromuscular disease of esophagus characterized by a distortion of the relaxation of the lower esophageal sphincter (LES) and manifested by marked clinical symptoms. To date, methods for diagnosing pathology and various surgical methods for its correction have been developed and actively used. In this review, the authors summarized all available data on principles of modern classification based on the identification of characteristic diagnostic criteria of the disease. The modern treatment methods are described in detail, the effectiveness of the presented methods is evaluated.

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.

Gastrointestinal Dysmotility and the Implications for Respiratory Disease

Purpose of the review

Gastroesophageal reflux disease (GERD) is frequently implicated as a cause for respiratory disease. However, there is growing evidence that upper gastrointestinal dysmotility may play a significantly larger role in genesis of respiratory symptoms and development of underlying pulmonary pathology. This paper will discuss the differential diagnosis for esophageal and gastric dysmotility in aerodigestive patients and will review the key diagnostic and therapeutic interventions for this dysmotility.

Recent findings

Previous studies have shown an association between GERD and pulmonary pathology in children with aerodigestive disorders. Recent publications have demonstrated the presence of esophageal and gastric dysfunction, using fluoroscopic and nuclear medicine studies, in aerodigestive patients who commonly present to pulmonary and otolaryngology clinics. High-resolution impedance manometry (HRIM) has revolutionized our understanding of esophageal dysmotility and its role in pathogenesis of aspiration and esophageal dysfunction and subsequent respiratory compromise.

Summary

Esophageal and gastric dysmotility have a profound effect on development of respiratory symptoms and pulmonary sequalae in aerodigestive patients. However, our understanding of the pathophysiology is in its infancy. Prospective studies in are needed to address key clinical questions such as: What degree of dysmotility initiates respiratory compromise? What diagnostic tests and therapeutic options best predict aerodigestive outcomes?

Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials

BACKGROUND

Achalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM.

METHODS

A thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed.

RESULTS

A total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31-0.82; P = 0.009 and OR: 0.47; CI 0.22-0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33-1.19; P = 0.34).

CONCLUSION

PD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a "0-IIb+IIa" lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage.

Achalasia: current therapeutic options

Achalasia is a chronic incurable esophageal motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and loss of esophageal peristalsis. Although rare, it is currently the most common primary esophageal motility disorder, with an annual incidence of around 1.6 per 100,000 persons and prevalence of around 10.8/100,000 persons. Symptoms of achalasia include dysphagia to both solids and liquids, regurgitation, aspiration, chest pain and weight loss. As the underlying etiology of achalasia remains unclear, there is currently no curative treatment for achalasia. Management of achalasia mainly involves improving the esophageal outflow in order to provide symptomatic relief to patients. The most effective treatment options for achalasia include pneumatic dilation, Heller myotomy and peroral endoscopic myotomy (POEM), with the latter increasingly emerging as the treatment of choice for many patients. This review focusses on evidence for current and emerging treatment options for achalasia with a particular emphasis on POEM.

New insights into the pathophysiology of achalasia and implications for future treatment

Idiopathic achalasia is an archetype esophageal motor disorder, causing significant impairment of eating ability and reducing quality of life. The pathophysiological underpinnings of this condition are loss of esophageal peristalsis and insufficient relaxation of the lower esophageal sphincter (LES). The clinical manifestations include dysphagia for both solids and liquids, regurgitation of esophageal contents, retrosternal chest pain, cough, aspiration, weight loss and heartburn. Even though idiopathic achalasia was first described more than 300 years ago, researchers are only now beginning to unravel its complex etiology and molecular pathology. The most recent findings indicate an autoimmune component, as suggested by the presence of circulating anti-myenteric plexus autoantibodies, and a genetic predisposition, as suggested by observed correlations with other well-defined genetic syndromes such as Allgrove syndrome and multiple endocrine neoplasia type 2 B syndrome. Viral agents (herpes, varicella zoster) have also been proposed as causative and promoting factors. Unfortunately, the therapeutic approaches available today do not resolve the causes of the disease, and only target the consequential changes to the involved tissues, such as destruction of the LES, rather than restoring or modifying the underlying pathology. New therapies should aim to stop the disease at early stages, thereby preventing the consequential changes from developing and inhibiting permanent damage. This review focuses on the known characteristics of idiopathic achalasia that will help promote understanding its pathogenesis and improve therapeutic management to positively impact the patient’s quality of life.

Idiopathic hypereosinophilic syndrome presenting with hepatitis and achalasia

Idiopathic hypereosinophilic syndrome (HES) is a rare diagnosis defined by the World Health Organization as a persistent eosinophilia for 6 months and resulting in end-organ dysfunction. While many patients present with nonspecific symptoms, others will present with symptoms of the affected organs, most commonly those involving the heart, skin, or nervous system. Gastrointestinal or liver involvement is estimated to affect up to one-third of patients with HES, although patients with clinically significant disease are limited to case reports. This is the first report of a patient presenting with hepatitis and achalasia related to idiopathic HES.