Safety and Efficacy of Graded Gradual Pneumatic Balloon Dilation in Idiopathic Achalasia Patients: A 24-Year Single-Center Experience

Background: Pneumatic balloon dilation (PBD) is a first line treatment for idiopathic achalasia. Here we report the safety and efficacy of graded gradual PBD on short and long-term follow-up. Methods: We evaluated 1370 idiopathic achalasia patients over a period of 24 years (1994-2018), prospectively. 216 patients did not undergo PBD due to comorbid diseases. Ultimately, 1092 achalasia patients were enrolled. All patients underwent graded gradual PBD, with repeat dilation if symptoms relapsed. Response to treatment was evaluated by Vantrappen scoring system. Results: Of 1092 achalasia patients, 937 patients were treated by PBD and 155 patients were treated by combined therapy (PBD 1 month after Botulinum toxin injection). In short-term follow-up, 728 of 1092 patients underwent one PBD and 77.3% of them had excellent or good response (responders), 163 patients (58.6%) who underwent two PBDs were responders, and 44 (51.2%) patients who underwent three PBDs were responders. Overall, 2193 balloon dilations were performed on 1092 patients (mean 2 PBDs/patient). Of 786 patients with long-term follow-up, 259 patients had excellent or good response with one PBD. The responders with two, three, and four or more dilations were 149, 67, and 67, respectively. The overall response rate was 69%. No any serious complications were noted by using the graded gradual method. Conclusion: Our results show that graded gradual PBD is a safe and effective method for treatment of achalasia patients, and achieves sufficient short and long-term symptomatic remission with high cumulative success rate.

Megaesôfago idiopático: relato de caso

o objetivo foi relatar um caso de megaesôfago idiopático que foi tratado por cardiomiotomia videolaparoscópica a Heller-Pinotti em um paciente masculino, de 29 anos. Foi realizada triagem inicial com anamnese e exame físico e o paciente alegou disfagia progressiva sem alterações dos hábitos intestinais associadas; exame físico abdominal sem alterações. A investigação diagnóstica laboratorial incluiu tireoideopatia, doença de Chagas e doença do refluxo gastroesofágico. Após extensa investigação foi detectada acalasia (confirmada por esofagomanometria) idiopática, sendo assim realizada a cardiomiotomia videolaparoscópica a Heller-Pinotti. Posteriormente ao tratamento cirúrgico, o paciente apresentou boa evolução pós-operatória, não havendo queixas de pirose ou regurgitação e desaparecendo a queixa de disfagia. Declara-se boa experiência com o tratamento cirúrgico proposto, no entanto, novos estudos se tornam necessários para aprimoramento da técnica cirúrgica e consequente maior benefício para o paciente com acalasia idiopática. the goal was to report a case of idiopathic achalasia that was treated by Heller-Pinotti’s videolaparoscopic cardiomyotomy in a male patient of 29 years. The initial assessment was done with clinical history and physical examination and the patient claimed progressive dysphagia without changes in bowel habits associated; abdominal physical examination without abnormalities. Laboratory diagnostic investigation included thyroidopathy, Chagas’ disease and gastroesophageal reflux disease. After extensive research, it was detected idiopathic achalasia (confirmed by esophageal manometry) and Heller- Pinotti’s videolaparoscopic cardiomyotomy was realized. After surgery, the patient presented good postoperative evolution, with no complaints of heartburn or regurgitation and the dysphagia complaint had gone. We can declare good experience with the proposed surgical treatment, however, further studies are needed to make improvements in surgical technique and consequent greater benefit to the patient with idiopathic achalasia.

Advances in the diagnosis and treatment of achalasia of the cardia: A review

Idiopathic achalasia is an esophageal motor disorder characterized by the loss of the lower esophageal sphincter ganglion, resulting in impaired lower esophageal relaxation and absence of esophageal peristalsis. Patients commonly present with progressive dysphagia accompanied by reflux, heartburn, retrosternal pain, and severe weight loss. Diagnosis is primarily based on the patient’s chief complaints, barium esophagography, and the most recent high-resolution manometry. Endoscopic assessment and endoscopic ultrasonography also have significant value with regard to the exclusion of esophageal anatomical lesions, neoplastic diseases, and pseudoachalasia. However, as most patients with achalasia demonstrate a gradual onset, early diagnosis is difficult. Currently, treatment of idiopathic achalasia, including pneumatic dilation, stent placement, and surgical myotomy, is aimed at reducing lower esophageal sphincter pressure and relieving the symptoms of dysphagia. Peroral endoscopic myotomy has gradually become the mainstream treatment because it causes less trauma and has a rapid recovery rate. This article reviews the main methods of diagnosis and treatment of achalasia, with an emphasis on the potential of peroral endoscopic myotomy and the advancements of immunotherapy for achalasia.

A Bitter Pill to Swallow: Pseudoachalasia Secondary to Oesophageal Deviation Resulting from Mediastinal Shift and Left Atrial Enlargement after Left Lower Lobectomy

Pseudoachalasia, also known as secondary achalasia, is a rare clinical condition mimicking idiopathic achalasia but unrelated to primary loss of nitrergic innervation. It has mostly been attributed to malignancy infiltrating the oesophageal wall, but several other benign underlying pathologies have been reported. Because of similar manometric appearance, high-resolution manometry (HRM) of the oesophagus alone cannot distinguish between idiopathic achalasia and pseudoachalasia. Misdiagnosis can result in ineffective treatment by dilatation or even more invasive therapy. This is the first case-report of pseudoachalasia secondary to oesophageal deviation resulting from mediastinal shift and left atrial enlargement following prior left lower lobectomy. HRM, the gold standard for the diagnosis of achalasia, confirmed the incomplete relaxation of the lower oesophageal sphincter (LES) in absence of normal oesophageal peristalsis. However, additional workup with CAT scan and cardiac ultrasound identified an anatomical shift by the extrinsic mass effect resulting from the atrial enlargement, but without contrast retention at the LES.