Esophageal achalasia detected by vomiting during induction of general anesthesia: a case report

Background Esophageal achalasia is a rare disease with a high risk of aspiration during anesthesia induction. Here, we describe our experience involving a case of undiagnosed esophageal achalasia with profuse vomiting during anesthesia induction. Case presentation A 58-year-old woman was scheduled for orthopedic surgery under general anesthesia. She vomited a large amount of watery contents during anesthesia induction, and planned surgery was postponed. After recovery from anesthesia, she informed us that she usually had to drink a large amount of water to get food into her stomach and purged watery vomit every night before sleep. However, she attributed it to her constitutional problem, not to a specific disease. She was subsequently diagnosed with esophageal achalasia and underwent Heller myotomy with Dor fundoplication before her re-scheduled orthopedic surgery. Conclusions A detailed history of dysphagia and regurgitation should be taken in preoperative examinations to prevent unexpected aspiration due to undiagnosed achalasia.

Efficacy and Safety of Peroral Endoscopic Myotomy for Esophageal Achalasia and Achalasia-Related Diseases in Patients Aged 75 Years and Over

Peroral endoscopic myotomy (POEM) has become a popular treatment for esophageal achalasia and other esophageal motility disorders. However, its efficacy and safety in elderly patients are unclear. To clarify that, we reviewed the medical records of patients who underwent POEM in our hospital. A total of 11 patients who underwent POEM for esophageal achalasia (n = 10) and jackhammer esophagus (n = 1) were included. Procedural success, defined as the completion of an esophageal and gastric myotomy, was 100%. Clinical success, defined as an Eckardt score of 3 or less, without the use of additional treatments at 2 months, was 100%. The median Eckardt score significantly decreased after the POEM (baseline vs. 2 months after POEM; 7 (2-8) vs. 0 (0-1), p < 0.01). In the second and third years, the cumulative treatment effect maintenance rate was 88.9%. All patients taking antithrombotic agents had safe operations with the temporary discontinuation of these agents. There were four adverse events (two pneumoperitoneum, one mucosal injury, and one pneumonia), all of which improved with fasting or antibiotics. In conclusion, POEM is an effective and safe treatment for esophageal achalasia and achalasia-related diseases in patients aged 75 years and over.

Surgical Treatment of Esophageal Advanced Achalasia

Of the several procedures that has to treat esophageal achalasia, the esophagectomy is to be the most indicated in advanced disease, which prompted Pinotti the disseminate the transmediastinal esophagectomy technique in the 1970s, with the advantage of avoiding thoracotomy. Nevertheless, several series demonstrated that this technique was not exempt from complications one of which could lead to massive hemopneumothorax due to injury to the trachea- bronchial tree and vessels due the periesophagitis that may be present with consequent adherence of the esophagus to these noble organs. Thus, Aquino in 1996 introduced the esophageal mucosectomy technique with preservation of the esophageal muscle tunic at the level of mediastinum as well as the transposition of the stomach to the cervical region inside in this tunic for the reconstruction of digestive tract. The advantage of this procedure is to avoid transgression of the mediastinum. This author describes in details this procedure, and shows early results and late evaluation using the ECKARDT score in a series of patients showing the advantages of the esophageal mucosectomy due the low incidence of immediate postoperative complications and good resolution in long term due the absence of symptoms in most patients.