Frequency of Herpes Virus (HSV) in Esophageal Muscle Samples among Patients with Achalasia under Heller Myotomy

Background Despite years of research, the etiology of achalasia not well understood. Scientists suppose a role for autoimmunity, in this disorder, and probable viral agent, such as herpes virus (HSV). The aim was to find out the frequency of HSV in esophageal muscle samples in patients with achalasia under Heller's myotomy. Methods In this study, 60 patients with achalasia, after fulfilling the consent form, were underwent Heller’s myotomy surgery. Biopsy samples prepared for polymerase chain reaction (PCR) method for HSV DNA detection. After DNA-extraction, replication performed using specific primers. Results The mean age was 40.62 ± 5.08 years. Thirty-nine patients (65%) were female and 21 (35%) were male. Thirty-eight (63.3%) had no history but the else (36.7%) had a positive history of HSV. HSV-1 was positive in three patients (5%). Two females and one male were HSV-positive. Conclusions HSV-1 frequency is not notable among Iranian patients with achalasia. We suggest exploring other viruses, in special that involving the pathogenesis of achalasia, with a larger sample size.

Resolution of symptoms after Heller's cardiomyotomy with DOR fundoplication versus endoscopic balloon dilatation in patients with achalasia Cardia at tertiary care hospital

Objective: The objective was to compare symptoms improvement following Heller's myotomy with DOR fundoplication (HM-DOR) and endoscopic pneumatic dilatation (PD) for the treatment of achalasia cardia at one year follow up. Methods: This prospective comparative study was conducted at department of upper GI and minimally invasive surgery, Civil hospital Karachi from February 2016- January 2019. All patients diagnosed as a case of achalasia cardia on esophageal manometry were included in this study. Subjects were grouped into two treatment groups: Endoscopic Pneumatic Dilatation(PD) and laparoscopic Heller's myotomy with DOR fundoplication (HM-DOR). Results: A total of 42 patients were taken into study, of which 21 patients were randomly assigned in each of the two groups (surgery and endoscopic). Mean age of patients undergoing laparoscopic Heller’s myotomy and endoscopic pneumatic balloon dilatation was 34±8.59 and 37±12.87 years respectively. Treatment success in PD group was 52% (11/21) as compared to HM-DOR group which was 76% (16/21). Post Eckardt scores reduction at 1 year follow up between PD and HM-DOR were statistically significant (p<0.001). Patient satisfaction measured by likert's scale was significantly more in the surgery group. Conclusion: The efficacy of HM appears to be greater than PD for improvement in dysphagia and overall patients satisfaction score over a 1 year follow up period. Keywords: Esophageal achalasia, Heller’s myotomy (HM), Endoscopic pneumatic dilatation (PD). Continuous...

Optional Management of Achalasia in 2021: Dilatation or Myotomy

Achalasia cardia is a primary motility disorder of the esophagus, defined by lack of normal esophageal peristalsis along with inadequate relaxation of lower esophageal sphincter . The mainstay of management in achalasia includes pneumatic dilatation, Heller’s myotomy and peroral endoscopic myotomy (POEM). Pneumatic dilatation and Heller’s myotomy have gained maturity over several decades. The current best practice with regard to pneumatic dilatation is graded and on-demand dilatation in appropriately selected cases with type I and II achalasia. Laparoscopic Heller’s myotomy plus partial fundoplication is minimally invasive with reduced postoperative reflux and has virtually replaced open Heller’s myotomy with or without fundoplication. The subtyping of achalasia using high-resolution manometry bears prognostic significance and may help in choosing appropriate therapeutic modality in these patients. Since all the three modalities are effective for type I and II achalasia, the choice among these depends on the availability, expertise, and patient’s preferences. On the other hand, POEM is more effective than pneumatic dilatation and Heller’s myotomy and, therefore, preferred in type III achalasia. Although POEM is effective across the spectrum of esophageal motility disorders, the incidence of gastroesophageal reflux is high and needs to be considered while choosing among various options in these patients. In cases with failed POEM, redo POEM appears to be effective in alleviating symptoms.

PERORAL ENDOSCOPIC MYOTOMY IN TREATMENT OF THE ESOPHAGEAL ACHALASIA AT CHILDREN

Etiological treatment of esophageal achalasia are absent. None of the currently available treatment methods can restore normal esophageal peristalsis and the functionality of the lower esophageal sphincter, thereby alleviating dysphagia and other symptoms of achalasia. Therapeutic procedures currently used for the effective treatment of achalasia of the esophagus are represented by laparoscopic Heller's myotomy and endoscopic balloon dilatation of the esophagus. According to the literature, Heller's myotomy is considered as a method of choice in children, since it provides more reliable results in comparison with pneumatic expansion during prolonged observation. Peroral endoscopic myotomy (POEM) is a new endoscopic method for the treatment of esophageal achalasia, first reported by P. Pasricha in experiment, and then H. Inoue performed this operation in adult patients. There are only a few studies on the use of POEM in children and adolescents. Existing studies have demonstrated the feasibility of this procedure in children, low level of complications and excellent results with short-term observation. Several studies have reported high efficacy in the use of POEM in children, ranging from 90% to 100%. Reports of the occurrence of complications after POEM in children are sporadic and are represented by the formation of subcutaneous emphysema, carboperitoneum, retroperitoneum and mediastinal emphysema. Obviously, detailed studies with longer observation are required before the role of POEM in the treatment of esophageal achalasia in children can be established. If preliminary results are confirmed, POEM can be a real alternative to Heller's myotomy in pediatric patients. This study is intended to explore the potential and safety of the use of POEM for the treatment of achalasia in children based on a review of existing data in the scientific literature.

Peroral Endoscopic Myotomy in a Patient with Achalasia Cardia with Prior Heller’s Myotomy

Achalasia cardia is an esophageal myenteric plexus disorder characterized by absence of or incomplete lower esophageal sphincter relaxation and esophageal aperistalsis; Heller’s myotomy is the main treatment of choice due to a lower failure rate. Recently, peroral endoscopic myotomy (POEM) has been reported as an alternative treatment for achalasia due to persistent symptoms after Heller’s myotomy. An Indian male, aged 18 years, was admitted to the hospital due to dysphagia which had started more than 3 years ago. He also complained of occasional regurgitation and retrosternal pain with Eckardt score 6. Heller’s myotomy was performed 2 years ago. Barium swallow showed achalasia cardia and upper gastrointestinal endoscopy found liquid residue and resistance at the gastroesophageal junction. Esophageal manometry is concluded as achalasia cardia type II with a median integrated relaxation pressure (IRP) of 25.6 mm Hg. He underwent POEM; with the help of a submucosal tunnel, an extension of up to 1 cm beyond the gastroesophageal junction could be achieved with a posterior orientation of myotomy. There were no adverse events after the POEM procedure. He was treated with a soft diet for 10 days and other supportive treatments. Following POEM, barium swallow showed a significant improvement and esophageal manometry exhibited that the basal lower esophageal sphincter pressure was normal with complete relaxation on swallowing and normal median IRP. The post-procedure Eckardt score was 0. We reported an achalasia patient who received POEM after unsuccessful Heller’s myotomy and showed clinical improvement.