Achalasia Cardia In Indian Children– Experience From A Tertiary Care Institute In Chennai, India

Introduction:Achalasia cardia a rare oesophageal motility disorder is not uncommon in children. Aim and objectives:To describe the clinical profile of achalasia from a single pediatric tertiary care centre. Materials and Methods: Retrospective analysis of case records over a period of 10 years from March 2008 to March 2018 at institute of child health and hospital for children, Chennai, India. Results: 26 children had achalasia and 11 (42.3%) were males. The mean age was 42.08±36.33 months and 19 (73.07%) were less than five years at diagnosis. Vomiting was the most common symptom (88.4%) followed by failure to thrive (80.77%). Six had features of Allgrove syndrome. Heller's cardiomyotomy with or without fundoplication was done in 24 (92.3%) and pneumatic dilatation in two. Conclusion: Achalasia cardia is not uncommon and should be considered in children presenting with vomiting, dysphagia and failure to thrive. Surgery remains to be safe and effective.

Control study of peroral endoscopic myotomy and pneumatic dilation in patients with primary achalasia / 中华消化杂志

Objective To explore the difference in short-term efficacy between peroral endoscopic myotomy (POEM) and pneumatic dilatation (PD) in achalasia patients.Methods A retrospective analysis was applied.From September 2010 to March 2015,patients with POEM or PD were enrolled and divided into POEM group (n=26) and PD group (n=40).High-resolution manometry (HRM) before and one month after treatment were compared between POEM group and PD group.Before and three months after treatment,Eckardt score and gastroesophageal reflux symptom was compared between groups (Eckardt score ≤ 3 as the standard for successful treatment).Wilcoxon signed rank test was performed for before and after treatment comparison in the same group.Mann-Whitney U test was used to compare between two groups and Fisher's exact test was used for rate comparison.Results The successful treatment rates at one and three month after POEM group were 92.3 ％ (24/26) and 96.2％ (25/26),respectively.The successful treatment rates at one and three month after PD were 87.5％ (35/40) and 75.0％ (30/40).At three month after treatment,the successful treatment rate of POEM group was higher than that of PD group (Fisher's exact test,P =0.02).At three months after treatment,the Eckardt score of POEM group was lower than that of PD group (1.35,0 to 4.00,vs2.73,0 to 6.00;U=-3.921,P＞0.01).By the end of three months after treatment,the rate of gastroesophageal reflux symptom of POEM group was higher than that of PD group (7/26,26.9 ％ vs 2/40,5.0％;Fisher's exact test,P=0.01).The postoperative 4 second integrated relaxation pressure (4s-IRP) and lower esophageal sphincter pressure (LESP) of POEM group were both lower than those of PD group (7.01 mmHg,3.48 to 10.40 mmHg vs 10.11 mmHg,5.75 to 12.91 mmHg,U=-4.541,P＜0.01;11.61 mmHg,4.21 to 14.64 mmHg vs 17.85 mmHg,8.39 to 24.57 mmHg,U=-6.142,P＜0.01).The analysis of achalasia subtypes indicated that the efficacy of POEM was better than that of PD both in type Ⅰ and type Ⅱ.Conclusion During short-term follow-up,the efficacy of POEM was better than that of PD in achalasia patients,however there was a higher incidence of post-operative gastroesophageal reflux after POEM.

Estrategias terapéuticas en el tratamiento de la acalasia esofágica / Therapeutical strategies in the treatment of esophageal achalasia

Introducción: la acalasia es un trastorno degenerativo de la motilidad esofágica cuyo resultado es la ausencia o pobre relajación del esfínter esofágico inferior a la deglución asociado a trastorno motor del cuerpo esofágico. Afecta a ambos sexos con una incidencia de 1/100 000 y una prevalencia de 10/100 000. En su fisiopatología se han involucrado factores inmunológicos, genéticos, infecciosos y neurodegenerativos, que conllevan a pérdida selectiva de las neuronas inhibitorias del plexo mientérico e infiltrado inflamatorio en el esfínter esofágico inferior. Objetivo: revisar las modalidades terapéuticas en el tratamiento de la acalasia con un análisis a corto y largo plazo de las opciones de tratamiento. Métodos: con la introducción para su diagnóstico de la manometría de alta resolución se ha creado un novedoso sistema de clasificación que puede evaluar el pronóstico para el paciente y predecir la respuesta al tratamiento. La terapéutica descansa sobre la base de: tratamiento médico, procederes endoscópicos y tratamiento quirúrgico, siendo éste el estándar terapéutico, aunque continúa el debate sobre qué método es mejor, si la dilatación neumática, o la miotomía de Heller. Resultados: la miotomía laparoscópica de Heller (MLH) ha emergido en los últimos años como el tratamiento de elección, particularmente en pacientes jóvenes (≤ 45 años). Desde noviembre del 2012 hasta septiembre del 2015 se han realizado 27 dilataciones endoscópicas,15 mujeres (55,6 por ciento) y 12 hombres (44,4 por ciento), sin reportar complicaciones. Desde enero 2010 hasta diciembre 2014 se realizaron 188 miotomías de Heller por abordaje laparoscópico, el promedio de estadía hospitalaria fue de un día, no hubo conversión ni reintervención y la mortalidad fue nula(AU)

Introduction: Achalasia is a neurodegenerative motility disorder of the esophagus resulting in failure of the lower esophageal sphincter to relax properly in response to swallowing and associated to motor disorder of the esophageal body. It affects both sex with an incidence rate of 1/100 000 and a prevalence of 10/100 000. Its pathophysiology includes immune, genetics, infectious and neurodegenerative factors that result in a selective loss of inhibitory neurons of the myenteric plexus and inflammatory infiltrate in the lower esophageal sphincter. Objective: Objectives: To review the therapeutic modalities in the treatment of achalasia with short- and long-term analysis of treatment options. Methods: Through the introduction of high resolution manometry, a novel classification system for achalasia has been created to evaluate the prognosis of a patient and to predict response to treatment. Therapeutics is based on medical treatment, endoscopic procedures and surgery, being the latter the gold standard; however there is currently much debate over whether pneumatic dilation is better than Heller myotomy procedure in the treatment of achalasia. Results: Laparoscopic Heller myotomy has emerged in the last few years as the treatment of choice, particularly for young patients 45 years of age or younger. From November 2012 to September 2015, 27 endoscopic dilations have been perfomed in 15 women (55.6 percent) and 12 men (44.4 percent) with no reported complications. From January 2010 to December 2014, one hundred and eighty eight laparoscopic Heller myotomies were performed; the hospital stay was one day, neither conversion nor reoperation was necessary and the mortality rate was zero(AU)

A Case of Postfundoplication Dysphagia without Symptomatic Improvement after Endoscopic Dilatation

Laparoscopic fundoplication is a treatment option for gastroesophageal reflux disease refractory to medical treatment. When deciding whether or not to undergo surgery, patients with refractory gastroesophageal reflux disease and esophageal motility disorder need to fully understand the operative procedure, postoperative complications, and residual symptoms such as dysphagia, globus sensation, and recurrence of reflux. Herein, we report a case of a patient diagnosed with gastroesophageal reflux disease and aperistalsis who underwent Nissen (total, 360degrees) fundoplication after lack of response to medical treatment and subsequently underwent pneumatic dilatation due to unrelieved postoperative dysphagia and globus sensation.

Long-term Efficacy of Pneumatic Dilatation in Primary Achalasia / 대한소화기내시경학회지

BACKGROUND/AIMS: Pneumatic dilatation has been accepted as the preferred nonoperative treatment modality for primary achalasia. However, long-term effect of pneumatic dilatation on the primary achalasia has not been documented in Korea. The aim of this study was to evaluate the long- term efficacy of pneumatic dilatation and to obtain prognostic factors in primary achalasia. METHODS: Sixty four patients were enrolled retrospectively between August 1987 and July 2000. Diagnosis of primary achalasia was made by esophagogastroscopy, esophagography and esophageal manometry. Pneumatic dilatation was performed using 10 psi of 30-40 mm balloon for 1-2 sessions. We evaluated clinical efficacy of pneumatic dilatation by medical record review and phone interview, and analyzed prognostic factors by univariate and multivariate analyses. RESULTS: The clinical remission rates were 95%, 82%, and 76% at 1, 5, and 10 years, respectively. Univariate analysis showed that pneumatic dilatation was significantly more effective when the lower esophageal sphinter pressure (LESP) was reduced over 13 mmHg after treatment. Multivariate analysis demonstrated that LESP reduction tended to be a prognostic factor of primary achalasia in spite of no statistical significance. CONCLUSIONS: Pneumatic dilatation could be an effective therapy for primary achalasia. Reduction of LESP as a prognostic factor should be confirmed by a large-scale prospective study.

Progress in intervention procedure of Achalasia / 介入放射学杂志

Achalasia is a primary esophageal motility disorder, with the main symptom of dysphagia; and caused by the tonus increase and abnormal relaxation of the lower esophageal sphincter(LES). The etiology remains unclear, the objective of the current treatment approaches for achalasia containing the reduction of the LES tone and obstruction to relieve the patients' symptoms; including pharmacologic treatment, botulinum toxin treatment, surgical myotomy, pneumatic dilatation and cardia stent dilatation. The temporary cardia stent dilatation possesses some better advantages and effects; and ought to be the first choice of minimal invasive interventional management for achalasia.