esophagus. Complete regression was demonstrated in 34 of 106 (32%) patients with intestinal metaplasia, and in 55% of those with short segments ( 7 cm), hiatal hernia, or the presence of an epiphrenic diverticulum. The rate of esophageal perforations during pneumatic dilation is approximately 2%. The current recommendations regarding pneumatic dilation prior to (or instead of) surgical therapy depends upon the referring physician’s opinions, the surgeon’s expertise, and the patient’s preference. Although the ultimate goal of both medical and surgical therapy is the alleviation of symptoms, surgical therapy imparts a mechanical solution to GERD whereas medical therapy is aimed at acid suppression.
The internal tissue of the esophagus generally appears normal in endoscopy, although a “pop” may be observed as the scope is passed through the non-relaxing lower esophageal sphincter with some difficulty, and food debris may be found above the LES. Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, “achalasia” usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung’s disease. The immense success of laparoscopic surgery as an effective treatment of gastroesophageal reflux disease (GERD) and achalasia has established minimal invasive surgery as the gold standard in the surgical treatment of these two conditions.
In some people, very hot or very cold foods may trigger an episode. Normally, contractions of the esophagus (the tube that connects the mouth and the stomach) move food from the mouth to the stomach with a regular, coordinated rhythm. Late complications are related to recurrent dysphagia. Incomplete myotomy, perihiatal scarring, peptic stricture, or obstructing tumors can all cause recurrent symptoms. Proponents of cardiomyotomy without fundoplication cite their shorter operative times, diminished risk of causing dysphagia, and ease at which GER can be treated with modern acid suppression medication.
The innermost circular muscle layer of the esophagus is divided and extended through the LES until about 2 cm into the gastric muscle. Since this procedure is performed entirely through the patient’s mouth, there are no visible scars on the patient’s body. Johnson WE, Hagen JA, DeMeester TR, Kauer WK, Ritter MP, Peters JH, Bremner CG. Outcome of respiratory symptoms after antireflux surgery on patients with gastroesophageal reflux disease. Lord RV, Kaminski A, Oberg S, Bowrey DJ, Hagen JA, DeMeester SR, Sillin LF, Peters JH, Crookes PF, DeMeester TR. Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication.
At two week follow up, both patients are without complication and doing well. Once the patient has completely healed from their myotomy, we plan to perform an endoscopic intralumenal fundoplication for antireflux purposes.
Your physician may suspect achalasia based on your symptoms and physical examination. Achalasia should be suspected if you have difficulty swallowing both solids and liquids and you have regurgitation that has not resolved despite treatment with proton pump inhibitors. Proton pump inhibitors are a class of medications that are commonly used to treat acid reflux and include Prilosec, Nexium, and Dexilant.
The proximal extent of the myotomy is typically carried 5-6 cm proximal to the lower esophageal sphincter. Whether to carry the distal extent of the traditional 1-2 cm beyond the LES or to be more aggressive and carry the myotomy at least 3 cm onto the stomach is now debated. Oelschlager et al found less dysphagia and subsequently fewer interventions to treat the recurrent dysphagia in favor of the at least 3 cm distal myotomy group (3% vs 17%).
- The dilation of the LES is considered the most effective nonsurgical treatment of achalasia.
- Esophageal dilation, or stretching, is the preferred option in most cases.
- The diagnosis is made after exclusion of another cause, such as a mechanical obstruction (for example, a tumor of the GEJ).
Once he sees inside, he makes a small cut to the internal lining of your esophagus. He tunnels through it to reach the inner muscle of the lower esophagus, where he makes another cut.
This relaxation reduces the pressure in the LES. Another medication called sildenafil (Viagra) has also been shown to reduce pressure in the LES. Other medications may be used depending on the situation and discretion of your physician. Esophageal spasms can occur after a person eats certain foods, but can also be triggered by stress, medications, or GERD.
Patients present with progressive dysphagia and varying degrees of regurgitation, aspiration, chest pain, and weight loss. Misdiagnosis as gastroesophageal reflux disease (GERD) is a common reason for delay in treatment in patients with achalasia.
Achalasia is a motility disorder of the esophagus characterized by the defective peristaltic activity of the esophageal body and impaired relaxation of the lower esophageal sphincter due to the degeneration of the inhibitory neurons in the myenteric plexus of the esophageal wall. The histopathological and pathophysiological changes in achalasia have been well described. However, the exact etiological factors leading to the disease still remain unclear. Currently, achalasia is believed to be a multifactorial disease, involving both extrinsic and intrinsic factors.