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Query: UMLS:C0014848 (achalasia)
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The primary aim of this study was to identify factors that influence outcome of the surgical treatment of achalasia. A secondary aim was to compare outcomes after laparoscopic Heller myotomy and partial fundoplication using either a Dor or Toupet hemifundoplication. Between 1994 and 2002, a total of 78 patients underwent laparoscopic Heller myotomy and partial fundoplication. Preoperative investigations included esophageal manometry, a videoesophogram, and upper gastrointestinal endoscopy with biopsy. In 64 patients (35 males and 29 females), telephone contact was possible at a median 24 months (IQR 14-34). A Dor fundoplication was performed in 41 patients and a Toupet fundoplication in 23. Symptoms were assessed prior to surgery and at follow-up by an independent physician using standardized definitions to grade the severity of dysphagia, regurgitation, and chest pain. To assess outcome, dysphagia was categorized as persistent or resolved. Persistent was defined as dysphagia that occurred on a weekly or daily basis. Resolved was defined as dysphagia that occurred occasionally or not at all. At follow-up, patients were asked to make a personal evaluation of their outcome as to whether (1) their swallowing was improved by the procedure, (2) they were satisfied with the outcome, and (3) they would undergo surgery again under the same circumstances. There was a significant improvement in dysphagia and regurgitation scores after surgery (P<0.05). The scores for chest pain/heartburn remained unchanged. By physician assessment, dysphagia was resolved in 49 patients (77%) and persisted in 15 (33%). By patient assessment, 62 patients (97%) reported an improvement in the symptom of dysphagia, and 60 (94%) stated that they were satisfied with their improvement and would undergo surgery if they had to make the choice again. On univariate analysis, patients who had resolution of their dysphagia had a significantly higher resting lower esophageal sphincter (LES) pressure prior to myotomy (P=0.01) and on multivariate analysis only a high resting LES pressure prior to surgery was a predictor of resolution of dysphagia (P=0.015). Outcome comparison of patients with Dor and Toupet fundoplications showed no significant differences in physician assessment of postoperative symptom scores and resolution of dysphagia, patient assessment of outcome, or postoperative use of proton pump inhibitors. Ninety-four percent of patients are satisfied with their surgical myotomy for achalasia. By physician assessment dysphagia was resolved in 77% of patients. A high LES resting pressure before surgery predicted resolution of dysphagia.
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PMID:Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. 1501 30

Endoscopy-negative reflux disease is used to describe a heterogeneous group of disorders with symptoms that mimic those of gastroesophageal reflux disease in the absence of visible esophageal injury at endoscopy. Compared with patients who have gastroesophageal reflux-related erosive esophagitis, those with endoscopy-negative disease are more likely to be younger, female, of lower body weight, and without a hiatal hernia. Approximately 50% of those with endoscopy-negative reflux have abnormal intraesophageal acid exposure and are considered to have nonerosive acid reflux disease. Those with symptoms of >12 consecutive or intermittent weeks' duration during the prior year, with normal acid exposure and without achalasia or other motility disorder with a recognized pathologic basis, are considered to have functional heartburn. In the absence of pathologic reflux, a number of etiologies may contribute to the symptoms of heartburn, including motor events, reflux of nonacidic gastric contents, minute changes in intraesophageal pH (pH <4), visceral hypersensitivity, and emotional or psychological abnormalities. Although persons with endoscopy-negative reflux disease experience decrements in their quality of life that are similar to those for individuals with erosive esophagitis, the response to traditional therapies for acid reflux may differ between the 2 groups. Studies have found that approximately 50% of patients with endoscopy-negative reflux disease experience complete symptom relief after 4 weeks of proton pump inhibitor treatment. In those with persistent heartburn symptoms, other structural or nonacid reflux etiologies for their symptoms should be explored.
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PMID:Endoscopy-negative reflux disease: concepts and clinical practice. 1547 51

Esophageal dilation is the treatment of choice for most patients with esophageal dysphagia (functional and mechanical). Multiple forms of esophageal dilators are available. Mechanical dilators (guidewire/nonguidewire assisted) are the major forms of dilators used. Balloon dilator use has increased but they offer only a marginal advantage over traditional mechanical dilators at a greatly increased cost (2 degrees to single use). Comparative trials are biased in favor of balloon dilators, but balloon dilators are not indicated for empiric dilation for dysphagia. Empiric dilation for solid food dysphagia is still controversial. Dilation is rarely associated with complications and is rarely contraindicated unless previous dilation attempts have been unsuccessful. Special circumstances such as caustic strictures, radiation stricture, and dysphagia associated with eosinophilic esophagitis should engender cautious dilation. Attention to detail about placement of guidewires and stricture type are still critical for safety. Predilation barium studies are not needed in all patients but should be employed if the endoscope is not able to pass the stricture and stricture length and angulation are unknown. Intralesional steroids and proton pump inhibitor therapy are important adjuvant treatments for resistant strictures and reflux associated strictures. Balloon dilation for achalasia is still a viable alternative, but it is likely to decrease in usage with the advent of more widespread laparoscopic myotomy.
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PMID:Esophageal Dilation / Dilators. 1562 37

When patients with the typical reflux symptoms of heartburn, regurgitation, or both, undergo endoscopy, up to 75% will not have endoscopic oesophagitis or evidence of Barrett's oesophagus. These patients have been described as having endoscopic negative or, more commonly, non-erosive reflux disease (NERD). Patients without oesophagitis, but with a positive pH test, can be diagnosed with gastro-oesophageal reflux disease (GERD). Some experts also consider a response to proton pump inhibitor therapy as proof of GERD in a patient with the correct symptoms and a negative endoscopy. Patients with normal acid exposure, but who report symptoms with a majority of their reflux episodes documented during an ambulatory pH study, have also been considered to have NERD, although others have labelled them as having 'functional heartburn'. Finally, there are some patients who have reflux symptoms and respond to reflux therapy, but have no demonstrable reflux by either endoscopy or ambulatory reflux testing. Whether these patients are part of the GERD spectrum or have another diagnosis is not clear. It seems that the most widely used definition of functional disease (the Rome II criteria) would include these patients as having functional heartburn, as it was defined as 'greater than or equal to 12 weeks of either continuous or intermittent symptoms of burning retrosternal discomfort or pain without pathologic GERD, achalasia, or other motility disorders with a recognized pathologic basis'. This article reviews potential differences in pathophysiology between erosive oesophagitis and NERD; explores whether symptoms can help distinguish NERD patients from erosive oesophagitis patients; and explores the evaluation and therapy of these patients.
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PMID:Review article: the role of acid suppression in patients with non-erosive reflux disease or functional heartburn. 1648 68

Achalasia and gastroesophageal reflux disease (GERD) represent diverse physiologic disorders both of which result from lower esophageal sphincter (LES) dysfunction. Fortunately, both diseases are benign and amenable to surgically corrective therapies. Achalasia is characterized by destruction of the smooth muscle ganglion cells of the myenteric plexus (Auerbach) resulting in motor dysfunction, incomplete LES relaxation, and progressive esophageal dilation. GERD is frequently characterized by hypotonia or shortening of the LES. Local anatomical derangements such as a hiatal hernia (eg, sliding type I hernia) can predispose to GERD. Other predisposing factors for GERD include obesity, smoking, alcohol, and pregnancy. Transient LES relaxation is the most significant factor in the development of GERD. Transient LES relaxations last from 10 to 45 seconds and are not related to swallowing. The diagnostic workup of achalasia and GERD may include barium esophagram, upper gastrointestinal endoscopy, pH monitoring, and esophageal manometry. The different medical treatment options for achalasia comprise pharmacologic treatment, botulinum toxin, and balloon dilation. Surgical interventions include Heller myotomy, which is usually combined with a partial fundoplication. GERD is managed by treating the predisposing factors, using medications (ie, anatacids or proton pump inhibitors) and surgery (ie, fundoplication). Recently, endoluminal therapy has been employed in the treatment of GERD with promising short-term results.
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PMID:Recent advances in the surgical treatment of achalasia and gastroesophageal reflux disease. 1836 81

The aim of surgical treatment in achalasia cardia is symptom relief. Most studies have evaluated the results of laparoscopic cardiomyotomy with an antireflux procedure. However, data on the effectiveness of laparoscopic cardiomyotomy without an antireflux procedure is sparse. We describe our experience of laparoscopic cardiomyotomy without antireflux procedure in 40 consecutive patients with respect to symptom relief and complications. There was no mortality and 1 conversion. Preoperatively dysphagia, regurgitation, and heartburn were present in 40, 39, and 11 patients. At a mean follow-up of 26 months, there was a significant improvement in symptom scores. Two patients (5%) had persistent postoperative dysphagia. One improved on conservative therapy, whereas other was treated with relaparoscopic cardiomyotomy. Three patients (7.5%) developed heartburn in the postoperative period, which was well controlled with proton pump inhibitors. Laparoscopic cardiomyotomy without antireflux procedure results in excellent relief of dysphagia without producing significant symptomatic reflux in the follow-up.
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PMID:Symptomatic outcome of laparoscopic cardiomyotomy without an antireflux procedure: experience in initial 40 cases. 1842 30

Refractory gastroesophageal reflux disease (GERD) is very common and may affect up to 40% of patients who use a proton pump inhibitor (PPI) once daily. Refractory GERD can present as incomplete or lack of response to PPI therapy. The disorder is clearly driven by patients, who present with a wide range of symptom severity and frequency while on PPI treatment. Poor compliance and improper timing of PPI consumption should always be excluded before further evaluation of this patient population. The putative mechanisms for refractory GERD include weakly acidic reflux, duodenogastroesophageal/bile reflux, visceral hypersensitivity, delayed gastric emptying, psychological comorbidity, and concomitant functional bowel disorders. Reduced PPI bioavailability, rapid PPI metabolism, PPI resistance, nocturnal reflux, and Helicobacter pylori infection status have very limited roles in refractory GERD. The contribution of eosinophilic esophagitis to refractory GERD is still unknown. Pill-induced esophagitis, Zollinger-Ellison syndrome, achalasia, and other disorders are rarely responsible for PPI failure and usually are not confused with GERD.
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PMID:Refractory GERD: what is it? 1862 35

One of the potential consequences of carrying out a Heller's myotomy for achalasia is gastro-oesophageal reflux. Whether it is frequent or severe enough to warrant the routine addition of a fundoplication to the operation is debated. In this prospective series of all patients undergoing a myotomy using a minimally invasive method the incidence of gastro-oesophageal reflux disease is examined. It was found that in 124 patients who had been followed for at least 6 months, whereas mild heartburn was common (51 patients; 41%), in only 10 patients (8.2%) was a proton pump inhibitor required and there were no patients whose reflux was not controlled using standard medical treatment. Peptic oesophagitis was an infrequent endoscopic finding with only 3 of 40 patients with no or mild heartburn having mild oesophagitis and no patient on a proton pump inhibitor having active peptic oesophagitis. These findings suggest that the addition of a fundoplication to a Heller's myotomy to prevent gastro-oesophageal reflux disease is not essential.
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PMID:Myotomy for achalasia: to wrap or not to wrap? 1895 49

The laparoscopic Heller-Dor operation has been the procedure of choice for the treatment of achalasia. However, because the incidence of achalasia is low, reports on the outcome of surgical treatment for achalasia are limited. In this study, the therapeutic results after laparoscopic Heller-Dor operation for achalasia at a single university hospital were evaluated. Between August 1994 and July 2006, 100 consecutive patients underwent laparoscopic Heller-Dor operation. The therapeutic results after laparoscopic Heller-Dor operation were assessed based on complications, operation time, blood loss, postoperative hospital stay, and the standardized questionnaire for satisfaction by telephone or outpatient clinic interview. With respect to perioperative complications, lower esophageal mucosal perforation occurred in 14 patients, but all of them could be suture-obliterated laparoscopically. One patient was converted to laparotomy because of uncontrolled bleeding from the short gastric artery. The mean operative time was 169 minutes, and the mean perioperative blood loss was 22 mL. The median postoperative hospital stay was 7 days. Reflux esophagitis, which was seen in five patients, was treated successfully with a proton pump inhibitor. According to the standardized questionnaire for satisfaction, 77 patients rated their recovery as 'excellent', 17 as 'good', 4 as 'fair', and 2 as 'poor'; thus, the overall success rate was 94%. There were no significant differences in surgical outcomes by morphologic type and severity of esophageal dilatation; however, the success rate deteriorated significantly with progression of the morphologic type. Laparoscopic Heller-Dor operation is a safe and effective surgical treatment for achalasia.
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PMID:Results after laparoscopic Heller-Dor operation for esophageal achalasia in 100 consecutive patients. 1901 50

Esophageal manometry (EM) findings were reviewed in 14 (13 male) adults diagnosed with eosinophilic esophagitis (EE). One had complete nonperistaltic contractions (amplitude range = 30-180 mmHg) and incomplete relaxation of the lower esophageal sphincter (LES), suggesting vigorous achalasia. After 6 months of steroid therapy the repeat EM showed near-normal findings. One had total aperistalsis with contraction amplitudes less than 10 mmHg and a weak LES pressure (8 mmHg), criteria suggesting scleroderma. Two had low-amplitude (<30 mmHg) nonperistaltic contractions limited to the mid-esophagus. Criteria for nutcracker esophagus were met in two patients. Isolated low LES pressure (<15 mmHg) was observed in four patients who were also receiving proton pump inhibitors, and the remainder had normal EM findings. Our results found that EE can mimic all the categories of EM disturbances, with approximately 50% of our patients having a major impairment of smooth muscle function. The EM abnormality can be reversed to normal in some cases with appropriate treatment for EE.
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PMID:Disturbances of esophageal motility in eosinophilic esophagitis: a case series. 1970 17


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