Update in achalasia: what the surgeon needs to know

Achalasia is a motility disorder encountered by surgeons during the investigation and treatment of dysphagia. Recent advances in manometry technology, a widely accepted new classification system and a new treatment rapidly gaining international acceptance, have changed the working knowledge required to successfully manage patients with achalasia. We review the Chicago classification subtypes of achalasia with type II achalasia being a predictor of success and type III achalasia a predictor of treatment failure. We review per‐oral endoscopic myotomy as an emerging treatment option and its potential for improving the treatment of type III achalasia.     

THORACOSCOPIC CARDIOMYOTOMY FOR ACHALASIA

Twelve patients with achalasia treated by cardiomyotomy via a thoracoscopic approach have been studied prospectively. Seven patients had previously undergone balloon dilatation with an unsatisfactory result. The procedure was completed successfully in all patients without recourse to thoracotomy. Morbidity was minimal and postoperative stay averaged 4 days. The functional result was goodexcellent in 11 patients and fair in one.     

Surgical treatment of achalasia: A retrospective comparative study

A retrospective study carried out on 74 patients among 101 consecutive cases of achalasia of the esophagus operated from 1967 to 1989 is reported. On 21 patients observed between 1967 and 1975, a standard transabdominal Heller cardiomyotomy was performed (group A). From 1976 to 1989, the treatment of choice was a Heller myotomy associated with a modified Dor's fundoplication. In 80 consecutive cases (group B) the extension of myotomy was regulated by intraoperative monitoring of lower esophageal sphincter pressure. A 5-year follow-up with questionnaires, physical examination, and barium swallows was carried out on 16 patients in group A and on 58 patients in group B. In 75.6% of the cases (56 patients) follow-up examinations included esophageal manometry and 24-hour esophageal pH monitoring. Recurrence of dysphagia was recognized in 3 cases in group A (18.7%) and in 2 cases in group B (3.4%) (P=0.053); postoperative gastroesophageal reflux, measured as a percentage of total reflux time, showed a significantly lower mean value in group B than in group A (1.8% vs. 4.1%. P<0.01). This study suggests that an anti-reflux procedure lowers post-operative gastroesophageal reflux after Heller myotomy. Due to the low incidence of postoperative reflux and the negligible recurrence of dysphagia, Heller myotomy associated with a modified Dor's fundoplication may represent the surgical treatment of choice for achalasia of the esophagus.     

经腹Heller手术加绕食管后方胃底部分折叠治疗贲门失弛缓症

目的　探讨采用经腹贲门肌层切开 (Heller)加绕食管后方胃底部分折叠治疗贲门失弛缓症的疗效。方法　回顾性总结 48例贲门失弛缓症经腹Heller手术加绕食管后方胃底部分折叠治疗的近期及远期效果。结果　全组病例手术后恢复顺利 ,吞咽困难症状缓解 ,无手术并发症。 3 8例进行了食管动力学监测 ,术前末端食管括约肌压力 (LESP)为 ( 2 1 4 8±5 3 6)mmHg ,术后LESP为 ( 16 4 5± 4 12 )mmHg ,两者经统计学处理 (t检验 )无显著差异 (P >0 0 5 ) ,2 5例进行了术后 2 4hpH值监测 ,DeMeester记分均在正常范围。近期手术优良率 10 0 %。 3 1例进行了 13～ 15 6个月的随访。平均随访时间 75个月。随访病人均能正常生活和工作 ,3例有反流症状 ,其中 1例 2 4hpH值监测反流次数超过 5 0次。远期手术优良率 90 3 2 %。结论　经腹Heller手术加绕食管后方胃底部分折叠治疗贲门失弛缓症疗效满意 ,是一种安全有效的手术方式     

胸腔镜下行Heller手术治疗贲门失迟缓症的围手术期护理

目的探讨胸腔镜下行贲门肌层切开术（Heller手术）治疗贲门失迟缓症的围手术期护理体会。方法回顾性分析2010年1月～2011年4月本科室20例贲门失迟缓症患者在胸腔镜下行Heller手术治疗的临床资料,并总结围手术期的护理要点。结果 20例患者术程顺利,手术时间45～65min,平均（53.75±4.88）min;术中出血量20～30mL,平均（24.90±3.40）mL。经对症治疗和护理后,患者痊愈出院,无1例出现并发症;随访3～18个月,患者无复发。结论术前重视消化道准备及呼吸功能训练,术后严密观察病情变化,加强引流管护理,预防并发症,其是胸腔镜下行Heller手术治疗贲门失迟缓症取得成功的关键措施。     

Chest pain before and after laparoscopic cardiomyotomy for achalasia

Background: Laparoscopic cardiomyotomy usually achieves a good outcome for patients with achalasia. However, some patients continue to experience chest pain after surgery, even when symptoms such as dysphagia have resolved. In this study, we quantified chest pain and the impact of myotomy on this symptom. Methods: In 108 patients who underwent laparoscopic cardiomyotomy, chest pain was assessed before and after surgery. A standardized questionnaire evaluated chest pain, other symptoms including odynophagia, dysphagia and regurgitation, and overall satisfaction with the outcome of surgery. Results: The proportion of patients reporting chest pain was similar across all age groups and genders before and after surgery. Sixty‐five (60.2%) patients reported some chest pain after surgery. Of these, 47 (72.3%) also reported dysphagia, 9 (13.8%) odynophagia and 23 (35.4%) acid regurgitation (62.3%, 11.6% and 21.7% before surgery). Following surgery, there was a significant reduction in the frequency of chest pain (daily chest pain declined from 26.9% to 5.6%). Conclusions: Chest pain is common before and after cardiomyotomy for achalasia, and it is frequently associated with dysphagia. Whilst it is less problematic after surgery, it persists in many patients. This information should be provided to individuals considering surgery for achalasia.     

Laparoscopic Heller's cardiomyotomy achieved lesser recurrent dysphagia with better quality of life when compared with endoscopic balloon dilatation for treatment of achalasia

Achalasia is a rare primary motility disorder of esophagus; treatments include endoscopic balloon dilatation (EBD) and laparoscopic Heller's cardiomyotomy (LC). This study compared EBD versus LC for treatment of achalasia with focus on quality of life (QoL) and prevalence of post‐treatment gastroesophageal reflux disease. This was a retrospective cohort study of all patients diagnosed with achalasia older than 16 treated with either EBD or LC from January 1998 to April 2008. Patients' demographic data, comorbidities, postintervention GERD symptoms, QoL, recurrence of dysphagia, reintervention rate, hospital stay, and time to resumption of diet were collected. Sixty‐eight patients were recruited into the study (EBD n= 50; LC n= 18). A significant improvement in QoL was found in patients undergoing LC (0.917 vs. 0.807, P= 0.006). A higher proportion of patients treated with EBD developed post‐treatment gastroesophageal reflux symptoms (60.5% vs. 43.8%) when compared with LC, although statistically insignificant (P= 0.34). Patients treated with balloon dilatation had a greater percentage of recurrence of dysphagia (55.1% vs. 26.7%; P= 0.235) and need of reintervention (42.1% vs. 9.1%; P= 0.045). However, these patients had a shorter median hospital stay (1d [range 0–4]) and earlier resumption of diet (0d [range 0–3]). Although EBD is associated with a quicker perioperative recovery, LC accomplished a better QoL, lower incidence of recurrence of dysphagia, and need of reintervention after treatment for achalasia.     

Endoscopic approach to achalasia

Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/ or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearlyequivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.