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Query: UMLS:C0014848 (achalasia)
 2,804 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Current methods to evaluate patients with esophageal disease include barium swallow with fluoroscopy, which is useful in demonstrating structural defects. Disordered motility is better evaluated with a cine-esophagram. Recent application of radioisotopes has been useful in evaluation of esophageal reflux and the post-treatment of achalasia. Esophageal motility studies may evaluate lower esophageal sphincter and upper esophageal sphincter pressures and the response of the body of the esophagus to series of swallows. Since there is no "gold standard" for the evaluation of reflux esophagitis, some of the tests designed to evaluate reflux and the patient's reaction to acid in the esophagus include the acid infusion test, the standard acid reflux test, the acid clearance test, and 24-hour pH monitoring. Endoscopy with either the flexible or the rigid instrument is important for the diagnosis of obstruction or esophagitis and allows direct visualization of the esophagus. The treatment of reflux esophagitis is discussed. The differential diagnosis of dysphagia may include achalasia, diffuse esophageal spasm, and mechanical obstruction of the esophagus due to rings, webs, strictures, and benign or malignant tumors. The evaluation of dysphagia should include radiologic as well as endoscopic evaluation. Treatment of obstruction varies according to the nature of the lesion. The Mallory-Weiss syndrome or bleeding from the mucosal tears of the gastroesophageal junction and Boerhaave's syndrome, spontaneous esophageal perforation, are two disorders associated with vomiting. The Mallory-Weiss syndrome usually resolves without specific therapy, but a high index of suspicion is required for patients with chest pain after vomiting, as spontaneous perforation necessitates immediate surgery. Most diverticula need no treatment, but the Zenker diverticulum, if symptomatic, should probably be surgically repaired.
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PMID:Evaluation and management of diseases of the esophagus. 703 70

Twenty-two patients with a history of between one and four (average of two) unsuccessful prior esophageal operations for neuromotor dysfunction were treated with esophageal resection and replacement. Eleven (50%) had recurred reflux esophagitis in association with various disorders of motility: esophageal spasm in 4, achalasia in 3, scleroderma in 2, and esophageal atresia in 2. Eight (36%) had primary esophageal spasm and 3 (14%) had achalasia. Esophageal obstruction, regurgitation, and severe spasm were the most common manifestations of the inability to swallow normally. Transthoracic or transhiatal (blunt) esophagectomies were performed in 5 and 17 patients, respectively. The stomach, with a cervical esophagogastric anastomosis, was used for esophageal substitution in 15 patients. Six patients underwent a long-segment colonic interposition, and 1 patient with achalasia underwent a distal esophagectomy and short-segment colonic interposition. One patient undergoing transthoracic esophagectomy for achalasia died from unrecognized intraoperative bleeding into the opposite chest. There were no other operative deaths. Additional complications included transient hoarseness in 8 patients, chylothorax in 1, and anastomotic leak in 1. After an average follow-up of 25 months for the 21 surviving patients, ability to eat is regarded as good in 18 (85%), fair in 1 (5%), and poor in 2 (10%). In patients with incapacitating esophageal neuromotor disease, a more radical operative approach-esophagectomy--may be safer and more reliable than attempting another procedure and risking another failure. Esophagectomy ensures definitive elimination of the esophageal problem and as optimal an ability to eat as possible. Our experience suggests that the stomach, with a cervical esophagogastric anastomosis, offers a better functional esophageal substitute than does a colonic interposition.
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PMID:Esophagectomy: definitive treatment for esophageal neuromotor dysfunction. 711 44

Most failures or pseudo-failures of Heller's operation are due to an imperfect surgical technique. The procedure should include the entire muscular layer, extend as far upwards as possible and at least two to three cm downwards onto the stomach. Furthermore, it should be associated with an anti-reflux procedure. Eighty-one operations were performed in 70 patients who had previously undergone Heller's operation. Of the 42 patients presenting with recurrent achalasia, 21 had an insufficient Heller procedure upwards, 10 downwards and 11 in depth. Twenty-three patients had peptic esophagitis and three had periesophageal sclerosis. The management of these 70 reoperated patients included 36 iterative esophageal myotomies, 32 resections, four total duodenal diversions and two hiatal reconstructions. Repeated cardiomyotomies gave excellent results in 75% of cases and esophagogastric resection in 79%.
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PMID:Reoperation after Heller's operation for achalasia and other motility disorders of the esophagus: a study of eighty-one reoperations. 711 64

The major postoperative complications of esophagocardiomyotomy (ECM) for achalasia are peptic esophagitis due to gastroesophageal reflux and recurrence. According to other authors, the incidence of postoperative esophagitis is 15% ot 25%. We report the results obtained in 40 patients treated by our own surgical technique, which is based on precise anatomic and physiopathological criteria. With this technique an ECM without esophagogastric mobilization is performed via a lower thoracotomy with partial perihiatal phrenotomy. There were no intraoperative or postoperative deaths. Two patients had postoperative basal pleurisy which was cured easily in a short time. In 36 of these patients, a follow-up ranging between 15 years and 6 months revealed a complete remission of dysphagia. The patients had significant and speedy improvement in their general condition. Seven patients had substernal pyrosis when lying down, but this was relieved in a few months in six of them. In only one patient did it persist for 4 years after the operation. Ph-manometric serial control studies performed in all the patients revealed, except in one case, normal pressure and pH values in the lower esophagus. Because of these results, we consider our ECM technique very effective in the treatment of achalasia.
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PMID:New approach to esophagocardiomyotomy: report of forty cases. 712 Oct 46

The location and perimeter of the true muscular gastroesophageal junction or cardia were determined during operation in 6 patients with achalasia, in 20 control subjects, and in 40 patients with reflux esophagitis. These two latter groups were submitted to highly selective vagotomy, owing to duodenal ulcer in the control subjects and as part of the surgical technique in reflux esophagitis patients. The careful dissection and isolation of the distal 5-6 cm of the esophagus and esophagogastric junction permitted us to measure the location and perimeter very precisely. There was a very close correlation between the distance incisors-beginning of gastroesophageal sphincter measured preoperatively and the distance incisors-cardia measured during surgery. The cardia could be clearly identified by external inspection corresponding to the limit between the longitudinal muscle layer of the esophagus and the serosal surface of the stomach. The perimeter of the cardia in the patients with reflux esophagitis was significantly larger than the perimeter of the control subjects (p less than 0.001). Intraoperative manometry demonstrated that the external limit of the cardia corresponded to the beginning of the gastroesophageal sphincter. Patients with achalasia had significantly smaller perimeter than controls or reflux esophagitis patients (p less than 0.001).
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PMID:Perimeter and location of the muscular gastroesophageal junction or 'cardia' in control subjects and in patients with reflux esophagitis or achalasia. 732 21

Modern operative treatment of motor dysfunction of the esophagus began in 1949 with the recognition that anastomotic procedures that bypass or destroy the distal esophageal sphincter are associated with the development of reflux esophagitis and stricture. Thirty years later, reflux esophagitis related to esophagomyotomy or intrinsic esophageal disease remains the dominant concern and challenge. This review examines the current status of operative procedures for the management of three important primary disorders of esophageal motility: achalasia, diffuse esophageal spasm, and scleroderma. Relief of esophageal obstruction by esophagomyotomy or reconstruction is the common surgical goal. The addition of a fundoplication procedure to discourage esophageal reflux remains controversial in each disorder. Esophageal resection may become necessary when stricture persists or esophagomyotomy fails to provide lasting relief of dysphagia.
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PMID:Operation for motor dysfunction of the esophagus. 735 72

Currently conflicting opinions regarding the efficacy of esophagomyotomy alone as the preferred treatment for esophageal achalasia prompted this review of the results in 69 patients treated at the Lahey Clinic between January 1970 and January 1980. Preoperative symptoms were alleviated completely or partially in 92% of the 60 patients operated on more than 12 months ago and who were available for follow-up study (average: 42 months). Excellent or good results were achieved in 84% of patients. Only one of the poor results was due to reflux esophagitis. It is concluded that an antireflux procedure is not routinely necessary to prevent postoperative reflux esophagitis if the technique of esophagomyotomy follows certain specific guidelines.
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PMID:Esophagomyotomy for achalasia of the esophagus. 740 69

The results of Heller myotomy with Belsey fundoplication in the treatment of 32 patients with achalasia is reviewed. Eighteen who received no previous surgical treatment had good to excellent results. Fourteen patients who had undergone previous Heller myotomy without an antireflux procedure required further surgical treatment. Inadequate myotomy and reflux esophagitis were the causes of failure. In this group four patients who were treated by myotomy, Collis gastroplasty and the Belsey procedure still failed to achieve good to excellent results. The authors conclude that gastroplasty is contraindicated in patients with achalasia.
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PMID:Treatment of achalasia: esophagomyotomy with antireflux procedure. 744 64

We have reviewed and analyzed the clinical and radiographic features of 38 patients with proven carcinoma involving the esophagogastric junction. There were 29 cases of adenocarcinoma and nine of squamous cell carcinoma presenting with similar symptoms, surgical findings and radiographic characteristics. Features that suggest adenocarcinoma are: 1. mass or distortion of the gastric fundus; 2. short lesion; 3. smooth submucosal contour defect representing tumor undermining mucosa. Hiatus hernia was present in 17% of adenocarcinomas and 44% of epidermoid carcinomas but the association appears to be coincidental. Atypical forms of presentation such as lesions involving almost the entire esophagus or mimicking peptic esophagitis and achalasia are discussed and illustrated. Pertinent data from the literature is reviewed. In order to avoid errors in the roentgenographic diagnosis routine careful examination of the esophagogastric junction is recommended.
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PMID:Carcinoma of the esophagogastric junction. 746 59

After a wide revision of the Literature, the most frequent causes of failure in the surgical therapy of esophageal achalasia are described. Above all there is the uncorrect execution of the Heller's myotomy as for its upward and downward extension or its deepness. An uncorrect myotomy, in fact, might cause the persistence or relapse of pre-operative symptoms, such as dysphagia and regurgitation. A correct myotomy, according to the authors, should be always carried out with the aid of intraoperative manometry (IEM), which allows the documentation of the alterations caused by surgery in the area of the high pressure zone, which corresponds to the sphincter (LES). A correct myotomy must produce the complete annulment of such a pressure. This technique creates the conditions sufficient to the genesis of gastroesophageal reflux (GER), which is one of the most frequent causes of failure in the surgery of achalasia. In fact, it causes a reflux esophagitis which can quickly evolve into a stricture with the reappearance of dysphagia. It is essential, therefore, to combine always the Heller's procedure with an antireflux procedure, which can protect the esophagus from GER and at the same time does not produce a mechanical obstacle to deglutition. The Authors report their last experience based on 114 primary operations of Heller's myotomy + Nissen fundoplication, performed since 1985 to date. IEM has been always used both for controlling the completeness of the myotomy and for the "calibration" of the Nissen's. Two patients, which had undergone elsewhere a Heller's myotomy alone, have been operated of re-myotomy + Nissen fundoplication. One patient, also operated elsewhere of myotomy of the esophageal body for diffuse esophageal spasm (DES), complained of dysphagia and had manometrical evidence of LES dischalasia; this patient has been reoperated of Heller's myotomy + Nissen fundoplication; another patient suffering from a reflux stricture after a Heller's myotomy without antireflux procedure, has been treated with a Roux esophago-jejunostomy. A last patient operated by Heller's myotomy + Dor fundoplication presented alkaline esophagitis without dysphagia; the treatment consisted in a Roux gastro-jejunostomy + bilateral troncular vagotomy. These data bring to the conclusion that the best treatment of achalasia relapses is their prevention, only obtainable by a good primary therapeutic approach and the routine use of IEM. The IEM avoids incomplete myotomies and inadequate antireflux procedures related to the incompetence (reflux) or hypercompetence (dysphagia recurrence) of the fundoplication.
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PMID:[Failure of surgical treatment for achalasia: diagnosis and treatment]. 894 95


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