Elevated Intraesophageal Pressure in Patients with Achalasia: A Common and Important Manometric Finding

There is a subgroup of patients with achalasia in which manometry shows elevated intraesophageal pressure, expressed by elevation of esophageal baseline relative to gastric pressure. The aim of this study was to determine the prevalence of elevated intraesophageal pressure in patients with achalasia and its relationship to clinical, radiographic, endoscopic, and other manometric findings. Manometric studies of 62 patients with achalasia were analyzed and elevated intraesophageal pressure was considered any positive elevation of esophageal baseline relative to gastric pressure. Multiple regression analysis was used to determine independent risk factors associated with elevated intraesophageal pressure. Elevated intraesophageal pressure was found in 32 patients (51.6%). Lower esophageal sphincter pressure was the only independent variable associated with elevated intraesophageal pressure (P = 0.0167). Mean lower esophageal sphincter pressure was significantly higher in patients with elevated compared to those with normal intraesophageal pressure (34 +/- 1.96 vs 26.5 +/- 1.73 mm Hg; P = 0.006). In addition, lower esophageal sphincter pressure had a positive correlation with intraesophageal pressure (r = 0.49, P < 0.001). Conversely, no correlation was found between elevated intraesophageal pressure and various symptoms, disease duration, radiologic dilation, a finding of retained fluid during endoscopy, and esophageal length. We conclude that elevated intraesophageal pressure is a common manometric finding in patients with achalasia, with a prevalence of 51.6%, and is associated with significantly higher lower esophageal sphincter pressure.     

Esophageal achalasia secondary to mesothelioma

Summary Achalasia secondary to malignancy is rare, with most cases associated with gastric adenocarcinoma of the gastroesophageal junction. This report describes the clinicopathologic features of a 64-year-old man found to have mesothelioma as the cause of secondary achalasia. To our knowledge, this is the first case of secondary achalasia produced by a mesothelioma. We reviewed the English literature in regard to achalasia induced by tumors.This work was supported by the Veterans Administration.     

Management strategies for achalasia

Treatment options for achalasia include oral pharmacologic therapy, endoscopic injection of botulinum toxin, pneumatic dilation, and myotomy (conventionally by laparoscopy, but more recently by an endoscopic approach). Oral pharmacologic agents have fallen out of use because of insufficient efficacy and frequent side effects. Endoscopic injection of botulinum toxin is safe and has good short‐term effectiveness, but as the effect invariably wears off after a few months, this treatment is reserved for patients who are not candidates for more definitive treatments. Pneumatic dilation and surgical myotomy are currently considered the most effective treatments, with similar effectiveness in randomized controlled trials with follow‐up of up to 2 years. The risk/benefit ratio and choice of therapy depend on patient characteristics (age, comorbidities, disease stage, prior treatments), patient's preference, and locally available expertise. Treatment of patients who fail or relapse after initial therapy is challenging and the success rate of pneumatic dilation or myotomy in this group is lower compared with previously untreated patients. The recently developed peroral endoscopic approach to myotomy has achieved excellent results in early uncontrolled studies, but high‐quality randomized trials are needed to ensure widespread adoption is reasonable. Finally, retrospective data suggest that achalasia subtypes as defined by high‐resolution esophageal pressure topography may guide treatment choice, but confirmation in prospective outcome studies is awaited.     

针刺联合生物反馈治疗女性产后盆底失弛缓综合征

为探讨针刺联合生物反馈治疗女性产后盆底失弛缓综合征的疗效,选取产后42d的产妇进行盆底肌电图及肛管压力测定,评估其盆底功能,将临床便秘症状明显的40例产后盆底失弛缓综合征患者作为观察对象,随机分为治疗组和对照组各20例。对照组患者自己进行提肛锻炼,治疗组在对照组基础上应用针刺联合生物反馈治疗。比较两组在治疗前、后盆底肌力测定数据及临床症状的改善情况。结果显示,两组患者治疗后盆底肌力情况改善不明显;但肛门压力及临床症状得到明显改善,治疗组优于对照组,差异均有统计学意义（P〈0．05）。结果表明,针刺联合生物反馈治疗可有效改善女性产后盆底肛门压力及临床症状,从而提高患者的生活质量。     

Change in cross‐sectional area of esophageal muscle does not correlate with the outcome of achalasia after pneumatic balloon dilatation

Background and Aim: Patients with achalasia have a thicker muscularis propria compared to normal patients. Because pneumatic balloon dilatation (PD) is an effective treatment for achalasia, the changes in the esophageal muscles after PD may predict treatment outcomes, if muscular change is of primary importance. In the present study, we aimed to observe the changes in esophageal muscle thickness following PD and assessed whether symptom relapse can be predicted on the basis of the esophageal muscle cross‐sectional area (CSA), as measured by high‐frequency intraluminal ultrasound (HFIUS). Methods: Fifteen patients treated by PD were studied and followed up for a median of 3.6 years. An HFIUS was done before PD and 6 months after PD. The esophageal muscle CSA measured at the lower esophageal sphincter (LES), and 3 and 6 cm above the LES, was used to see whether any association was present between symptom recurrence and the esophageal muscle CSA. Results: A single PD resulted in a 2‐year remission rate of 66%. A significance variance in change (?65%–248%) was noticed in the muscle CSA after PD. The predilation muscle CSA, post‐dilation muscle CSA, and change in the muscle CSA after PD was not associated with symptom recurrence. Conclusion: Our findings suggest that measuring the muscle CSA does not help to predict treatment outcome. Muscular changes in achalasia might be just reactive changes.     

Evaluation of early events in the creation of amyenteric opossum model of achalasia

Abstract Benzyldimethyltetradecylammonium chloride (BAC) has previously been used to create amyenteric rat jejunal models. Fifteen opossums (D. virginiana) were injected with 10–15 mL 4 mM BAC or saline in the distal oesophagus and along with controls underwent oesophagoscopy, manometry and barium oesophagrams. Atropine and sodium nitroprusside were studied in six of the BAC-treated and five controls using oesophageal manometry. Histologically several neuronal markers, B-NADPH-diaphorase and acetylcholine esterase histochemical staining were used. NADPH-diaphorase activity was assayed at the lower oesophageal sphincter (LOS) and 3 and 5 cm above LOS in both groups. Oesophagoscopy of the treated animals showed no mucosal inflammation, or strictures. Manometrically, LOS pressures were significantly higher in the BAC-treated group (25.7 ± 8.6 mmHg) when compared to controls (8.7 ± 1.8 mmHg). The oesophageal contraction amplitudes were similar in both groups. While sodium nitroprusside (SNP) significantly reduced the LOS pressure, atropine did not alter the resting LOS pressure in the BAC-treated animals. Histologically at the LOS the treated group showed: (i) absence of myenteric neurons, in contrast to prominent NADPH-diaphorase and other neuron and peptide markers in the control and (ii) ***increàse in the number of nerve bundles that were not positive for AchE. No differences were seen in the oesophageal body between the groups. The NADPH-diaphorase assay showed a significant decrease of activity in the BAC-treated LOS, but no differences in the oesophageal body compared to controls. Several of these radiologic, manometric and histological observations resemble features of achalasia and the mechanism of the tonic pressure increase at this early time point appears to be due to a non-cholinergic mechanism.     

The combination of Hirschsprung's disease and achalasia

The unusual combination of Hirschsprung's disease and Achalasia in one case treated by standard procedures led to the discussion about RET germ-line mutations and consequently to the speculation about higher risk for multiple endocrine neoplasia syndrome type 2-related tumors. Although a mutation could be excluded by sequence analysis in this case, the correlation of these specific diseases affords additive investigations to make sure that no further prophylactic procedures were necessary.     

Wound healing of laparoscopic esophageal myotomy with or without an added gastric patch

Background: The purpose of this research is to compare the wound healing of the laparoscopic esophagomyotomy with and without a gastric patch. Methods: Twelve male pigs were distributed into two groups of six animals. Esophagomyotomy was performed in group A. A gastric patch was associated to the myotomy in group B. On the 21^st postoperative day, lumen molding was accomplished to determine the index of stenosis (IS) at the area of myotomy (AM). Macroscopic and microscopic aspects of wound healing were also studied at AM. Three microscopic morphologic patterns were defined for morphometric evaluation: leukocytes (constituted by polymorphonuclear and mononuclear cells), new endothelial cells, and collagen fibers. Results: There was a longer operative duration in group B (93.6 min) than in group A (45 min). At AM, IS was negative (lumen increased) and equivalent in both groups: −11.1% in group A and −12.7% in group B. Mesotelial epithelium covering RM was observed in group A. Inflammatory reaction was greater in group B in comparison with group A (leuCocytes: 22 cells versus 8.6; fibrosis: 25.5 fibers versus 15.6; granulation tissue: 18.7 vessels versus 9.7). Conclusion: Esophagomyotomy followed by gastric patch does not heal adequately and is worsened by the presence of foreign body granulomas around stitches. Myotomy without gastric patch is faster and causes lower inflammation. Myotomy alone or with gastric patch does not lead to esophageal stenosis at RM and does not lead to restoration of the esophageal musculature continuity.     

Extremely Well Differentiated Adenocarcinoma of the Stomach Diagnosed Preoperatively as Esophageal Achalasia: Report of a Case

Extremely well differentiated primary gastric adenocarcinoma, which accounts for less than 0.2% of all gastric cancers, is associated with a better prognosis than other types of differentiated adenocarcinoma. Among 2070 gastric carcinomas, diagnosed between 1983 and 2002 at Fukuoka University Hospital and Hamanomachi Hospital, there were three cases of primary extremely well differentiated adenocarcinoma. We report the clinicopathological details of one case of primary gastric extremely well differentiated adenocarcinoma. A 57-year-old man was reffered to our hospital for investigation and treatment of a gastric tumor. Physical and laboratory examinations revealed no abnormalities except for diabetes mellitus. Radiological, endoscopic, and imaging examinations showed an esophageal achalasia-like stenotic lesion. The surface mucosa consisted of almost normal epithelium without any signs of malignancy. Macroscopically, the surgical specimen contained a submucosal tumor, and histological examination revealed extremely well differentiated adenocarcinoma. Although this type of carcinoma is very rare, it should be considered in the differential diagnosis of esophageal and gastric mucosal lesions.     

Esophagocardioplasty with gastric patch in the treatment of achalasia

Result of operative treatment in 196 cases of achalasia was reviewed. The procedures employed include cardiolysis, Heller's extramucosal myotomy, Wendel's cardioplasty, Heyrovsky's esophagocardiostomy, with and without pyloroplasty, cardiac resection and esophagocardioplasty with gastric patch. Follow-up study on 166 cases revealed that the result was classified as good in 99 cases or 59.6 per cent and improved in 46 cases or 27.7 per cent. Overall satisfactory result was obtained in 87.3 per cent. When the result was broken down to groups following three classifications, i. e. according to X-ray, endoscopic and manometric findings, the interesting correlation emerged. Heller's myotomy and esophagocardioplasty with gastric patch gave best results in early stage of achalasia, while in later stage the latter procedure seems to be the operation of choice.