ABSTRACT
AIM: Achalasia, also known as Esophageal achalasia, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter (LES). It is characterized by incomplete LES relaxation, increased LES tone, and lack of peristalsis of the esophagus (inability of smooth muscle to move food down the esophagus) in the absence of other explanations like cancer or fibrosis. In our experience, the echo-guided injection technique is the first procedure to implement to cure patients. After endoscopic-echo-guided injection technique, in patients presenting with refractory symptoms, the authors believe in surgical technique (extramucosal myotomy) as a good alternative technique to be implemented. METHODS: From 1999 to 2010, the authors have treated 36 patients (Group A), 24 male and 12 female (age 26-78) with diagnosis of esophageal achalasia. Patients underwent botulinum toxin injection during echo-guided identification of the lower esophageal sphincter. Results were compared with 32 patients (Group B) (age 36-78) who underwent blind treatment. RESULTS: Patients of Group A presented complete relief of obstruction, patients of Group B had an obstruction remission in the 86% of the cases. Results were confirmed by manometric assessments in the early months after endoscopic treatment. CONCLUSION: The authors emphasize the importance of the injection of botulinum toxin into the thicker area of the muscle layer of the lower esophageal sphincter. Patients undergoing echo-guided injection technique presented complete relief of obstruction, confirmed by manometric assessments in the early months after treatment.
Subject(s)
Anti-Dyskinesia Agents/administration & dosage , Botulinum Toxins/administration & dosage , Esophageal Achalasia/drug therapy , Esophagoscopy , Ultrasonography, Interventional , Adult , Aged , Female , Follow-Up Studies , Humans , Injections/methods , Male , Middle AgedABSTRACT
AIM: Achalasia of the esophagus involves the entire esophagus from the upper esophageal sphincter (UES) to the lower esophageal sphincter (LES) together with a wide spectrum of physiopathological and clinical variations. Therefore, the need to know exactly the different involvement either of the body of the esophagus or the LES for each case is underlined. In our experience, the cineradiology is the only technique that allows a complete morphologic and functional study of the disease. It is through cinesophagography that we can exactly establish the extension of myotomy according to the physiopathological aspects that will suggest the most accurate surgical treatment. It is our opinion to perform a short myotomy, to the gastroesophageal junction, through an abdominal approach in grade II and III achalasia, when the most important physiopathological aspects involve only the LES area (hypertonic LES or dischalasia). We extend the myotomy from the LES up to the aortic arch through a thoracic approach. METHODS: From 1984 to 2002, we have treated 148 achalasic patients, 90 through an abdominal approach, 22 by VALS (Video Assisted Laparoscopic Surgery) and 36 through a thoracic approach. In the first 2 groups we performed a short myotomy with a Dor antireflux procedure, in the 3rd group we performed a long myotomy with a Belsey Mark IV antireflux procedure. RESULTS: Our trend to calibrate the surgical treatment on the physiopathological and morphofunctional data, allowed to optimize the post-operative clinical results, particularly with a better control of dysphagia. CONCLUSIONS: Surgical treatment of achalasia must be differentiated according to the pathophysiological basis in order to improve the surgical results.
ABSTRACT
Surgical repair of an hiatal hernia results in changes in the local anatomy of the cardia and fundus that may be difficult to interpret by radiological examination. Endoscopy can clarify the radiological changes resulting from surgery, such as pseudodiverticula and pseudotumors, and, when conducted as part of the routine follow-up program, may reveal uncommon complications.
