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

Achalasia is an esophageal motility disorder characterized by the failure of lower esophageal sphincter relaxation and the absence of esophageal peristalsis. The purpose of this study was to evaluate the clinical outcomes of patients undergoing laparoscopic esophageal myotomy and Toupet fundoplication for achalasia. A 9-cm myotomy was performed in most cases extending 7 cm above and 2 cm below the gastroesophageal junction. Severity of dysphagia, heartburn, chest pain, and regurgitation was graded preoperatively and postoperatively using a five-point symptomatic scale (0-4). Patients also graded their outcomes as excellent, good, fair, or poor. Between December 1995 and November 2000 a total of 49 patients (23 male, 26 female) with a mean age of 44.3 years (range 23-71 years) were diagnosed with achalasia. Mean duration of symptoms was 40.2 months (range 4-240 months). Thirty-seven patients (76%) had had a previous nonsurgical intervention or combinations of nonsurgical interventions [pneumatic dilation (23), bougie dilation (five), and botulinum toxin (19)], and two patients had failed esophageal myotomies. Forty-five patients underwent laparoscopic esophageal myotomy and Toupet fundoplication. Two patients received laparoscopic esophageal myotomies without an antireflux procedure, and two were converted to open surgery. One patient presented 10 hours after a pneumatically induced perforation and underwent a successful laparoscopic esophageal myotomy and partial fundoplication. Mean operative time was 180.5 minutes (range 145-264 minutes). Mean length of stay was 1.98 days (range 1-18 days). There were five (10%) perioperative complications but no esophageal leaks. There was a significant difference (P < 0.05) between the preoperative and postoperative dysphagia, chest pain, and regurgitation symptom scores. All patients stated that they were improved postoperatively. Eighty-six per cent rated their outcome as excellent, 10 per cent as good, and 4 per cent as fair. Laparoscopic anterior esophageal myotomy and Toupet fundoplication effectively alleviates dysphagia, regurgitation, and chest pain accompanying achalasia and is associated with high patient satisfaction, a rapid hospital discharge, and few complications.
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PMID:Laparoscopic anterior esophageal myotomy and toupet fundoplication for achalasia. 1173 Feb 22

To many nonsurgeons myotomy is considered an excessively invasive treatment for achalasia and has become a salvage procedure when esophageal dilation and botulinum toxin (botox) injections fail. We sought to examine our experience with videoscopic Heller myotomy to determine whether preoperative therapy predicts perioperative complications and long-term outcome. Videoscopic Heller myotomy was undertaken in 111 patients with achalasia between June 1992 and May 2000. Intraoperative endoscopy was used in all patients. Fundoplication was used selectively for patients with large hiatal hernias or as part of repair of esophageal perforation. Patients were asked to grade their dysphagia and reflux symptoms before and after myotomy on a scale of 0 (no symptoms) to 5 (severe symptoms). Patients were also asked to rate their outcome as excellent (no symptoms), good (greatly improved), fair (slightly improved), or poor (not improved) compared with their preoperative status. Patients were stratified on the basis of preoperative intervention (botox, pneumatic dilation, botox and pneumatic dilation, or no botox or dilation) and compared. Previous pneumatic dilation and/or botox injection had been undertaken before operation in 88 (79%) patients whereas 23 (21%) patients had no invasive preoperative therapy. The overall mean preoperative dysphagia score was 4.8+/-0.8 and mean preoperative reflux score was 3.3+/-2.1. Groups of patients undergoing preoperative interventions were similar to those patients not undergoing preoperative interventions in terms of preoperative symptoms, dysphagia scores, and reflux scores. Postoperative complications (13%) and perforations (8%) were slightly more common in patients who had undergone preoperative botox or dilation (P = not significant). Subjectively, operative myotomy was more difficult in patients who had preoperative botox or dilation. Patients had significant improvement in dysphagia, dysphagia score, reflux score, emesis/ regurgitation, and chest pain (P < 0.05) regardless of preoperative intervention. After myotomy patients who had never undergone botox or pneumatic dilation were less likely to have mild dysphagia compared with those with previous botox injections (30% vs 53%; P = 0.09), previous dilations (30% vs 54%; P = 0.09), or both (30% vs 59%; P = 0.04). As well, dysphagia scores were better if no preoperative therapy had been undertaken: botox 0.8+/-1.3, dilation 1.0+/-1.4, botox and dilation 1.0+/-1.3, and no therapy 0.3+/-0.7 (P < 0.05). Overall 97 per cent of patients stated that their symptoms were improved although more patients tended to have excellent or good outcomes if no preoperative intervention was undertaken (91%) compared with patients undergoing preoperative botox (86%), dilation (83%), or both (82%) (P = not significant). We conclude that videoscopic Heller myotomy is safe and efficacious particularly in patients who have not undergone previous endoscopic interventions. The difference in patients' outcomes based on preoperative therapy may be related to a less difficult operation in patients who forgo endoscopic therapy and elect to undergo early myotomy. Although videoscopic Heller myotomy provides good outcomes as a salvage procedure after failed dilations and/or botox injections for achalasia we advocate it as first-line therapy in reasonable operative candidates.
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PMID:Videoscopic heller myotomy as first-line therapy for severe achalasia. 1173 Feb 31

Although several modalities are available to investigate oesophageal motility disorders, manometry is the gold standard. The procedure is increasingly available in district general hospitals but the clinical utility of this investigation in this setting remains unclear. The aim in this study was to evaluate the use and outcome of oesophageal manometry in a district general hospital. Data on 100 consecutive oesophageal manometry procedures were analysed, taking into account the referral pattern, indications, and results. The indications were gastro-oesophageal reflux disease (preoperative assessment before fundoplication) (58), dysphagia (28), chest pain (12), and epigastric pain (2). Diagnoses were made using predefined standard criteria and were as follows: normal (41), non-specific motility disorder (NSMD) (38), achalasia (15), diffuse oesophageal spasm (4), and scleroderma (2). Of the 58 patients who had undergone manometry as a preoperative assessment of oesophageal motility, 27 (47%) were abnormal. Twenty five (43%) had NSMD and two (3%) had achalasia. Forty eight of these preoperative cases were combined with 24 hour pH recording, which confirmed acid reflux in 35 (73%). The experience reported here reflects the published evidence that the use of manometry is changing. It is now more commonly used for assessment before antireflux surgery and for dysphagia, and the use in the assessment of chest pain is declining. The findings confirm the importance of eliminating achalasia before inappropriate antireflux surgery.
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PMID:A review of oesophageal manometry testing in a district general hospital. 1179 70

This study aims to provide longitudinal prospective data on symptomatic outcome following Heller myotomy with fundoplication and to examine variables that might predict a poor outcome. Patients were prospectively followed by means of a biannual mailed questionnaire that assessed symptoms, satisfaction with the procedure, medication, and need for further intervention. Patients were classified as achieving a good or poor outcome based on predetermined criteria. Duration of clinical remission was determined using Kaplan-Meier curves. Between 1992 and 1999, 62 patients with at least 12 months' follow-up were categorized as having either a good outcome (41 patients) or a poor outcome (21 patients). The cumulative probability of a good outcome at 7 years was 37%. Dysphagia significantly increased over the follow-up period despite initial resolution. Patient variables (age, sex, symptom duration, esophageal dilatation, manometric findings) and operative factors (myotomy length, wrap type, case number mucosal perforation, primary therapy) were not demonstrated to influence outcome at 3 years. A comparison of Nissen fundoplication with partial fundoplication suggested increased dysphagia and chest pain in the Nissen group. Despite initial symptomatic relief, patients with achalasia suffer a progressive decline with recurrent dysphagia and regurgitation. The type of fundoplication used may contribute to these poor results.
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PMID:Functional outcome after Heller myotomy and fundoplication for achalasia. 1198 83

Achalasia is a disorder characterized by abnormal motility of the esophageal body and the lower esophageal sphincter, resulting in dysphagia, regurgitation, and chest pain. Treatment options for achalasia include Botulinum toxin injection, pneumatic balloon dilation, and surgical esophagomyotomy. The aim of this study was to determine the cost-effectiveness of these three strategies in the treatment of achalasia in adults. We constructed a Markov cost-effectiveness model comparing Botox injection, pneumatic balloon dilation, and laparoscopic esophagomyotomy as initial treatments of achalasia. Costs and probabilities were derived from the published literature. The utility for symptomatic achalasia was derived from a sample of patients with achalasia. Sensitivity analyses were performed. Over a five-year time horizon, pneumatic dilation was the most cost-effective treatment strategy for achalasia, with an incremental cost-effectiveness ratio of $1348 per quality-adjusted life-year compared to Botox. Although laparoscopic esophagomyotomy was more effective than the other treatment options, it was not cost-effective because of its high initial cost. In conclusion, pneumatic dilation is the most cost-effective treatment option for adults with achalasia. Further studies should examine the long-term relapse rates following treatment with Botox and more precisely determine the quality of life of symptomatic achalasia.
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PMID:The cost-effectiveness of treatment strategies for achalasia. 1214 11

The basic principle behind the treatment of achalasia consists of alleviating swallowing disorders by reducing resistance in the lower esophageal sphincter without inducing gastroesophageal reflux. Only a few studies are available on long-term results after operative treatment. Fifty-one patients were studied with regard to long-term results after open transabdominal extramucosal myotomy of the distal esophagus along with partial anterior fundoplication (Dor procedure). Clinical data were collected by standardized interviews, and symptoms were assigned a score ranging from 0 to 3 according to severity and frequency. The pre- and postoperative symptoms were comparable in 50 patients. The median duration of follow-up was 88 months (range: 12-160 months). Operative time was a median of 80 min. Two esophageal mucosal tears were recognized intraoperatively and promptly repaired. Postoperative morbidity occurred in two patients (3.9%). Very good or good long-term results after surgical therapy were achieved in 49 patients (96.1%). Forty-seven patients (92.2%) have no or rare dysphagia. The frequency of regurgitation as well as chest pain was also significantly reduced after surgery. Forty-nine patients (96.1%) either maintained or gained weight. Preoperative duration of symptoms, follow-up, age, and gender had no influence on the results (p > 0.05). Two patients (3.9%) mentioned occasional heartburn. Five patients (9.8%) took or still take proton pump inhibitors postoperatively. Severe stage IV symptoms due to peptic stricture and dolichomegaesophagus required reoperation in one patient (2%). The results show that myotomy and the antireflux procedure (semifundoplication) lead to long-term relief of dysphagia without inducing reflux at a low operative risk. Since long-term results are as yet not available for minimally invasive surgery, it remains to be seen if this operative technique will become the primary surgical procedure for this disease.
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PMID:[Long-term outcome of myotomy and semi-fundoplication in achalasia]. 1224 80

Gastroesophageal reflux disease, achalasia and esophageal spasms are the most frequent esophageal motility disorders and are associated with dysphagia and non-cardiac chest pain. The diagnosis of achalasia is based on manometric criteria. Pneumatic dilatation, laparoscopic myotomy, and the minimal invasive injection of botulinum toxin are therapeutic options. Long-term-pH-metry is the gold standard to diagnose gastroesophageal reflux disease. Proton pump inhibitors (PPI) are the first-line therapy in reflux disease. Esophageal manometry and pH-metry are essential investigations prior to an antireflux operation. The evaluation of chronic constipation refractory to medical treatment should include anal manometry, and MR-defecography for the diagnosis of anorectal outlet obstruction such as anismus which could be treated successfully by biofeedback therapy.
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PMID:[Gastrointestinal motility disorders relevant to general practice]. 1242 42

We reviewed our experience in the diagnosis and management of esophageal achalasia in 33 children over a 25-year period at a single center by a retrospective chart review of all patients diagnosed with achalasia between December 1, 1975 and January 30, 2001. There were 33 cases ranging from 5 months to 16 years of age at the time of presentation (17 boys and 16 girls). Although dysphagia and vomiting were the commonest presenting symptoms, weight loss, chest pain, coughing, and recurrent pneumonia also occurred in many patients. Barium contrast study of the esophagus was the initial diagnostic modality followed by esophageal manometry. An upper endoscopy was also performed in 78.7% of cases. Management was predominantly surgical; however, seven recently diagnosed patients opted for botulinum toxin (botox) injection as the first line of treatment. The follow-up duration varied from 10 months to 10 years (mean 4.71 +/- 3.2 years). Postsurgical complications included gastroesophageal reflux disease in five patients who had not received a simultaneous antireflux procedure and "residual achalasia" in two patients, who both responded to a single botox injection.
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PMID:A review of achalasia in 33 children. 1245 92

Some patients with achalasia complain of chest pain in addition to dysphagia and regurgitation. Chest pain is said to be most common in young patients who have been symptomatic for a short time, and who often have vigorous achalasia (distal esophageal amplitude >/=37 mm Hg). Although pneumatic dilatation is reported to improve chest pain in 20% of patients, the effect of laparoscopic Heller myotomy on chest pain is unknown. The aim of this study was to determine the following in achalasia: (1) the prevalence of chest pain; (2) the clinical and manometric profiles of patients with chest pain; and (3) the effect of laparoscopic Heller myotomy. Between 1990 and 2001, a total of 211 patients with achalasia were studied (upper gastrointestinal series, esophagoduodenoscopy, and manometry). A total of 117 patients (55%) had chest pain in addition to dysphagia and regurgitation; 63 (54%) of these 117 patients underwent laparoscopic Heller myotomy and Dor fundoplication. Median follow up was 24 months. Age (49+/-16 years vs. 51+/-14 years [mean+/-SD]), duration of symptoms (71+/-91 months vs. 67+/-92 months [mean+/-SD]), and presence of vigorous achalasia (50% vs. 47%) were similar in those with and without chest pain. Ten (16%) of the 63 patients with chest pain who underwent Heller myotomy had vigorous achalasia. Postoperatively chest pain resolved in 84% and improved in 11% of patients. There was no difference in clinical outcome between patients with and without vigorous achalasia. These data demonstrate the following: (1) chest pain was present in 55% of patients with esophageal achalasia; (2) chest pain was not related to age, duration of symptoms, or manometric findings; and (3) laparoscopic Heller myotomy improved chest pain in 95% of patients, regardless of the manometric findings. Thus laparoscopic Heller myotomy was highly effective in treating achalasia with chest pain.
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PMID:Achalasia and chest pain: effect of laparoscopic Heller myotomy. 1285 Jun 70

The aim of this study was to define the clinical presentation, motility characteristics, and prevalence and patterns of gastroesophageal reflux in patients with hypertensive lower esophageal sphincter (HTLES). HTLES was defined by a resting pressure measured at the respiratory inversion point on stationary manometry of greater than 26 mm Hg (ninety-fifth percentile of normal). One hundred consecutive patients (80 women, 20 men; mean age 54.7 years, range 23 to 89 years), diagnosed with HTLES at our institution between September 1996 and October 1999, were studied. Patients with achalasia or other named esophageal motility disorders or history of foregut surgery were excluded, but patients with both HTLES and "nutcracker esophagus" were included. The most common symptoms in patients with HTLES were regurgitation (75%), heartburn (71%), dysphagia (71%), and chest pain (49%). The most common primary presenting symptoms were heartburn and dysphagia. The intrabolus pressure, which is a manometric measure of outflow obstruction, was significantly higher in patients with HTLES compared to normal volunteers. The residual pressure measured during LES relaxation induced by a water swallow was also significantly higher than in normal persons. There were no significant associations between any of the relaxation parameters studied (residual pressure, nadir pressure, duration of relaxation, time to residual pressure) and either the presence or severity of any symptoms or the presence of abnormal esophageal acid exposure. Seventy-three patients underwent 24-hour pH monitoring, and 26% had increased distal esophageal acid exposure. Compared to a cohort of patients with gastroesophageal reflux disease but no HTLES (n=300), the total and supine periods of distal esophageal acid exposure were significantly lower in the patients with HTLES and abnormal acid exposure. Patients with HTLES frequently present with moderately severe dysphagia and typical reflux symptoms. Approximately one quarter of them have abnormal esophageal acid exposure on pH monitoring. Patients with HTLES have significantly elevated intrabolus and residual relaxation pressures on liquid boluses, suggesting that outflow obstruction is present.
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PMID:The hypertensive lower esophageal sphincter: a motility disorder with manometric features of outflow obstruction. 1285 Jun 84


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