Intermittent neck swelling: an unusual presentation of achalasia cardia

Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.

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387 LAPAROSCOPIC REDO HELLER’S MYOTOMY FOR ACHALASIA FOLLOWING WORSENING OF SYMPTOMS DUE TO AN INADEQUATE MYOTOMY AND INAPPROPRIATELY CHOSEN ANTIREFLUX PROCEDURE.

Diseases of the Esophagus ◽

10.1093/dote/doaa087.95 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

R Parshad ◽

E Verma ◽

R Sharma ◽

G Makharia

Keyword(s):

Balloon Dilatation ◽

Heller Myotomy ◽

Nissen Fundoplication ◽

Good Choice ◽

Uneventful Recovery ◽

Antireflux Procedure ◽

Barium Swallow ◽

Achalasia Cardia ◽

Post Operative Period

Abstract This patient underwent Laparoscopic heller's cardiomyotomy and Nissen fundoplication for Achalasia cardia at another institute. Following surgery his dysphagia worsened. Dysphagia persisted despite balloon dilatation. Patient was evaluated at our institute with Barium swallow and CECT thorax which showed dilated oesophagus with tight wrap. Patient was planned for laparoscopic re exploration. At surgery he had a Nissen wrap and inadequate extension of myotomy across the GE junction. Methods The video describes the procedure of laparoscopic dismantling of the wrap with extension of Heller myotomy and a Toupet Fundoplication. Results Patient had an uneventful recovery and had significant improvement in dysphagia at a follow up of 7 months. Conclusion Nissen Fundoplication is not a good choice of antireflux procedure in achalasia cardia patients following Heller Myotomy and can contribute to dysphagia in the post operative period. Extension of myotomy across the GE junction is critical to the success of Heller myotomy. Re-do surgery is difficult but can be be accomplished through approach in experienced hands. Video https://drive.google.com/file/d/1dhs-PlUm-ahDGF63VxxM0htB0dRiAGYJ/view?usp=sharing

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Achalasia Cardia - Case Report

TAJ Journal of Teachers Association ◽

10.3329/taj.v14i2.8393 ◽

1970 ◽

Vol 14 (2) ◽

pp. 85-87

Author(s):

Md Baharul Islam ◽

Md Khalilur Rahman ◽

Abul Kashem Sarker

Keyword(s):

Weight Loss ◽

Case Report ◽

Medical College Hospital ◽

Barium Swallow ◽

College Hospital ◽

Achalasia Cardia ◽

Medical College

A 45 years old man was admitted in the surgery unit-ll at Rajshahi Medical College Hospital with the complaints of prolonged dysphagia and regurgitation of food and saliva. The patient had some weight loss but no anorexia, Barium swallow oesophagus showed marked dilatation of oesophagus with regular tapering of its lower end. The patient was diagnosed as achalasia cardia and underwent oesophago-cardio-myotomy operation. The patient relieved from his symptoms. He was followed up for 1 year and found healthy. DOI: http://dx.doi.org/10.3329/taj.v14i2.8393 TAJ 2001; 14(2): 85-87

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386 LAPAROSCOPIC HELLERS MYOTOMY AND ANGLE OF HIS ACCENTUATION FOR ACHALASIA CARDIA: 10 YEARS EXPERIENCE FROM A SINGLE SURGICAL CENTRE.

Diseases of the Esophagus ◽

10.1093/dote/doaa087.94 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

R Parshad ◽

V Singla ◽

S Suhani ◽

H Bhattacharjee ◽

G Makharia ◽

...

Keyword(s):

Quality Of Life ◽

Heller Myotomy ◽

Laparoscopic Heller Myotomy ◽

Antireflux Procedure ◽

Barium Swallow ◽

Symptom Duration ◽

Life Questionnaire ◽

Achalasia Cardia ◽

Dysphagia Score

Abstract Achalasia is a rare disease with Laparoscopic Hellers cardio-myotomy (LHCM) being the gold standard surgical modality. An antireflux procedure is required along with myotomy to decrease the chances of reflux postoperatively. We have performed Angle of His Accentuation (AOH) as an anti-reflux procedure in 126 patients who underwent LHCM since 2010. This study presents the symptomatic and objective outcomes of LHCM with AOH. Methods Review of prospectively collected data of patients with Achalasia cardia undergoing LHCM with AOH from 2010–2019. Subjective symptoms were scored for dysphagia, heartburn, regurgitation and quality of life using scoring systems mentioned in table 1 and Achalasia specific health related Quality of life questionnaire (ASHRQoL). Objective tests included Timed Barium swallow, Endoscopy and high-resolution manometry. Patients were evaluated in pre and postoperative period at regular intervals. Success was defined as follows: Eckardt score of ≤3, Dysphagia score of 0/1, Regurgitation and heartburn score of 0, >50% clearance on timed barium swallow, IRP <15 and absence of esophagitis. Results 126 patients were operated during the study period with no mortality or conversion. Mean age was 33.5(years), symptom duration 49.8(months), 31 had preoperative dilatation. The mean operative time was 131 (minutes). Subjective outcome was available in all patients & objective data in 66. At median follow of 31 months (IQR 15–59) outcomes significantly improved (Table 1) with 93% having dysphagia relief. 14 (11%) had new onset heartburn; 6(4.7%) needed regular proton pump inhibitors. ASHRQoL improved significantly (59.51 to 19.57). Pre&post-operative IRP, Timed Barium and endoscopy available in 66,39 and 62 patients improved significantly. 6(9.6%) patients had endoscopic evidence of esophagitis (LA-A 3, B/C 3). Conclusion Laparoscopic Heller myotomy with Angle of His accentuation is safe simple and effective procedure for Achalasia cardia. It provides significant relief of symptoms, improvement in quality of life and improvement in objective parameters. Post- operative heartburn and esophagitis is acceptable. We recommend Angle of His accentuation as an adjunct to Laparoscopic Heller myotomy.

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A Rare Cause of Dysphagia and Weight Loss

Case Reports in Gastroenterology ◽

10.1159/000493919 ◽

2018 ◽

Vol 12 (3) ◽

pp. 640-645 ◽

Cited By ~ 1

Author(s):

Janelle B. Gyorffy ◽

Johanna Marowske ◽

John Gancayco

Keyword(s):

Weight Loss ◽

Connective Tissue ◽

Joint Pain ◽

Marked Improvement ◽

Esophageal Manometry ◽

Biologic Therapy ◽

Connective Tissue Disorder ◽

Barium Swallow ◽

Systemic Lupus Erythematous ◽

Imaging Studies

Mixed connective tissue disease (MCTD) is a rare connective tissue disorder with clinical features that overlap with systemic lupus erythematous, systemic sclerosis, and polymyositis. We report the case of a patient who presented with dysphagia, 25-lb weight loss, difficulty opening her mouth, and joint pain. Dysphagia workup showed a normal barium swallow and normal-appearing EGD but esophageal manometry consistent with severe dysmotility. Through further laboratory and imaging studies, the patient met the diagnostic criteria for MCTD. She had marked improvement in her dysphagia with steroids, biologic therapy, and intravenous immunoglobulin.

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349 LAPAROSCOPIC MANAGEMENT OF ACHALASIA CARDIA IN CHILDREN

Diseases of the Esophagus ◽

10.1093/dote/doaa087.77 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

K Haravu Ramprasad ◽

P Agarwal

Keyword(s):

Gold Standard ◽

Treatment Modality ◽

The Body ◽

Barium Swallow ◽

Pneumatic Dilation ◽

Complication Rates ◽

Gold Standard Method ◽

Efficient Treatment ◽

Achalasia Cardia ◽

Primary Treatment Modality

Abstract Achalasia Cardia is a rare motility disorder of esophagus and is characterized by increased pressure of Lower Esophageal Sphincter (LES) and reduced motility of the body. This results in functional obstruction and failure of relaxation of LES. This condition is relatively rare in young children (about 0.11/100,000 children) Methods A retrospective study was done on 16 Paediatric patients with Achalasia Cardia over a 9 year period from 2010–2018. All patients underwent Barium Swallow and also upper GI endoscopy. Among the 16 patients, 8 of the patients underwent CT scanning and 6 patients had undergone manometry which is the gold standard method for diagnosis. Laparoscopic Heller’s Cardiomyotomy is the primary treatment modality for Achalasia Cardia. All patients underwent Cardiomyotomy along with Anterior Dor Fundoplication. Of the 16 patients, 6 had undergone Pneumatic Dilation previously. Results Of the 16 patients, 14 underwent Laparoscopic Heller’s Cardiomyotomy and 2 had open surgery. There were no intraoperative or postoperative complications. Normal feeds were started after 24 hours and the feeds were well tolerated. All the patients had complete resolution of dysphagia with score reducing from 4 to 0. All of them were discharged within 2–3 days. Conclusion Laparoscopic Heller’s Cardiomyotomy is the gold standard treatment for treating Achalasia Cardia. It is a safe, successful and efficient treatment modality for children with Achalasia Cardia due to shorter hospital stay, lower complication rates due to increased level of expertise and immediate and long lasting symptomatic relief.

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P201 LAPAROSCOPIC TRANSHIATAL OMENTAL REPAIR OF IATROGENIC ESOPHAGEAL PERFORATION IN ACHALASIA

Diseases of the Esophagus ◽

10.1093/dote/doz092.201 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Nebbia Martina ◽

Riva Pietro ◽

Da Roit Anna ◽

Basato Silvia ◽

Pansa Andrea ◽

...

Keyword(s):

Esophageal Perforation ◽

Delayed Diagnosis ◽

Vital Signs ◽

Laparoscopic Approach ◽

Pleural Empyema ◽

Water Soluble ◽

Patch Repair ◽

Barium Swallow ◽

Esophageal Wall ◽

Left Hemithorax

Abstract Aim Laparoscopic transhiatal omental patch repair(OPR) of esophageal perforation after pneumatic balloon dilatation(PBD) for achalasia. Background&Methods In August 2018 a 72yrs woman with a history of dysphagia for solids and liquids, nocturnal regurgitation and chest pain had a diagnosis of achalasia. After inhalation during a barium swallow the patient developed fever, respiratory insufficiency and worsening of vital signs leading to ICU and intubation. She developed a right-pleural empyema, massive pneumothorax and right-upper lobe abscess, requiring thoracotomy and right-superior lobectomy. She had been scheduled for a Per Oral Endoscopic Myotomy in November. After the submucosal tunnel, the procedure had been suspended due to presence of fibrosis. In December the patient underwent a first PBD up to 30mm with symptoms resolution and 2kg weight regain. In February, few hours after a second PBD up to 35mm, she complained mild pain at the left hemithorax and fever. 24hrs later a CTscan with water-soluble-contrast revealed a 3cm long esophageal perforation 5cm above the diaphragm and left paraesophageal mediastinal abscess without pleural involvement. Endoscopic treatment was excluded for significant dilatation of the esophagus and the fragile esophageal wall. Because of the frailty status of the patient, the delayed diagnosis, the high risk of a direct suture of the esophageal wall through a left thoracotomy, the even higher risk of an emergency esophagectomy, we performed a laparoscopic approach. Limited dissection of the esophagogastric-junction and of the left diaphragmatic crura allowed access to the abscess cavity, no attempt to direct suture was done, a drain was placed, a pedicled omental flap was realized filling the cavity and repairing the esophageal defect. A jejunostomy was placed. Results The post-op period was uneventful; a CTscan with per-os contrast on POD3 and POD9 didn’t show any collection. The patient started an oral semisolid-diet on POD11. An EGDS on POD19 confirmed the presence of the OPR in the esophageal lumen and after 2-months showed a completely re-epithelialized esophagus. Conclusions Laparoscopic trans hiatal OPR of esophageal perforation in achalasia proved to be a minimally invasive and effective procedure in this patient due to its immunogenic and angiogenetic properties.

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Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis

World Journal of Surgery ◽

10.1007/s00268-019-04945-9 ◽

2019 ◽

Vol 43 (6) ◽

pp. 1563-1570 ◽

Cited By ~ 2

Author(s):

Manjunath Siddaiah-Subramanya ◽

Rossita Mohamad Yunus ◽

Shahjahan Khan ◽

Breda Memon ◽

Muhammed Ashraf Memon

Keyword(s):

Systematic Review ◽

Heller Myotomy ◽

Meta Analysis ◽

Achalasia Cardia

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Zenker’s diverticulum in an 85-year-old Ugandan man

BMC Gastroenterology ◽

10.1186/s12876-021-01914-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Senai Goitom Sereke ◽

Felix Bongomin ◽

Zeridah Muyinda

Keyword(s):

Weight Loss ◽

Clinical Suspicion ◽

Zenker’S Diverticulum ◽

Barium Swallow ◽

Significant Weight Loss ◽

Inexpensive Method ◽

Case Presentation ◽

Zenker's Diverticulum ◽

Proximal Esophagus ◽

One Year

Abstract Background Zenker’s diverticulum (ZD) is an uncommon disorder due to an outpouching of tissue through the Killian triangle that is thought to be caused by dysfunction of the cricopharyngeal muscle. Case presentation An 85-year-old male patient presented with odynophagia and dysphagia of initially solid food followed by fluids that was associated with a significant weight loss over a one-year period. Barium swallow videofluoroscopy demonstrated a posterior outpouching of proximal esophagus that was 2 cm from the epiglottis. With the diagnosis of medium sized ZD, the patient underwent endoscopy guided diverticulotomy. Six months after the procedure, he was asymptomatic and had gained weight. Conclusions Dysphagia and weight loss raises a clinical suspicion for a malignancy. Barium swallow examination is an inexpensive method for the diagnosis of ZD.

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