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

Botox injection and pneumatic dilation are common therapies for achalasia. We sought to determine the impact of these preoperative therapies on esophageal muscle histology and outcomes after laparoscopic Heller myotomy. A total of 73 consecutive patients had esophageal muscle biopsies taken from the gastroesophageal junction at the time of myotomy between November 1998 and November 2001. Muscle fibrosis was graded by a senior pathologist who was blinded to preoperative treatments and postoperative outcomes. Patients graded their dysphagia and heartburn symptoms before and after myotomy and graded their outcomes at follow-up. Patients were grouped according to the preoperative endoscopic treatment (dilation, Botox, both, or neither) and the groups were compared. Preoperative therapy did not correlate with esophageal fibrosis or postoperative outcomes, and the degree of esophageal muscle fibrosis was not predictive of outcome. Symptom scores improved significantly for dysphagia (4.5 +/- 0.9 vs. 1.6 +/- 1.6) and heartburn (2.3 +/- 1.8 vs. 1.5 +/- 1.4) irrespective of preoperative therapy or fibrosis. Overall, excellent or good outcomes were obtained in 92% of patients at follow-up of 15.7 months +/- 14.4. Successful outcomes are highly probable after laparoscopic Heller myotomy regardless of preoperative interventions. The amount of fibrosis in the esophageal muscle is not related to preoperative intervention and is not predictive of outcomes.
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PMID:Preoperative intervention does not affect esophageal muscle histology or patient outcomes in patients undergoing laparoscopic Heller myotomy. 1260 Apr 42

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

Epiphrenic diverticula are very rarely seen and are often associated with achalasia, esophageal body dysmotility, and a high resting lower esophageal sphincter pressure. The aim of this study was to evaluate the different treatment options for patients with epiphrenic diverticula. Patients with an epiphrenic diverticulum were divided into two treatment groups: surgical and nonsurgical. Retrospective chart review was performed, and a symptom questionnaire was created. There were six patients in the nonsurgical group and 11 patients in the surgical group. The mean follow-up was 26.4 months. Ten patients had a laparoscopic operation performed. One patient was operated on thoracoscopically and had to be converted to a thoracotomy. Two diverticula were inverted with good results. There was one postoperative esophageal leak where no myotomy was added. An empyema developed in another patient at 4 weeks after surgery. One patient, in whom no antireflux procedure was performed, reported postoperative heartburn. Patients in the nonsurgical group had smaller diverticula, were not good candidates for surgery, or were asymptomatic. Esophageal diverticula are very rarely seen. Asymptomatic patients may not require therapy. If surgery is performed and the diverticulum is large, it should be removed. The laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid esophageal leakage at the line of repair and gastroesophageal reflux.
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PMID:Management of epiphrenic diverticula. 1459 66

Achalasia is a primary oesophageal motor disorder characterised by the abnormal relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. It is a rare disease, with an estimated incidence of approximately 1/100,000 and a prevalence close to 10/100,000 [1]. Its exact aetiology remains unknown. Autoimmune, infectious, degenerative and hereditary processes have all been proposed as factors that lead to a chronic inflammatory response in the myenteric plexus, thus resulting in selective loss of inhibitory neurons [2] and failure of the LES to relax and aperistalsis in the body of the oesophagus. The most common symptoms of achalasia are dysphagia for solids and liquids, regurgitation, chest pain, weight loss and heartburn in > 90 approximately 75, 40 - 50, approximately 60, approximately 40%, respectively [3,4]. The diagnosis is based on symptoms, barium swallow and manometry. A barium oesophagram typically shows a dilated oesophagus that tapers into a 'bird-beak' at the gastro-oesophageal junction with lack of normal peristalsis on fluoroscopic evaluation. The characteristic manometric features of achalasia are abnormal LES relaxation and aperistalsis; additionally, the LES pressure is frequently high, but can also be normal. Current practice of medicine is faced with rising healthcare costs and limited budgets [5]. We are therefore confronted with an increasing demand to justify the value of our therapeutic interventions, not only from the risk/benefit standpoint but also from the cost perspective [6,7].
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PMID:Cost-assessment of alternative management strategies for achalasia. 1459 55

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

Catheter-based high-frequency intraluminal ultrasound imaging is a powerful tool to study esophageal sensory and motor function and dysfunction in vivo in humans. It can be combined with manometry, pH, and impedance measurement techniques to determine the relationships between different physiologic parameters. High-frequency intraluminal ultrasound imaging has provided a number of important insights regarding the longitudinal muscle function of the esophagus. On the basis of the ultrasound images and intraluminal pressure recordings, it seems that there is synchrony in the timing and the amplitude of contraction between the circular and longitudinal muscle layers. A sustained contraction of the longitudinal muscle layer is temporally related to esophageal chest pain and heartburn. The biomechanics of the esophageal wall and its relationship to sensory and motor function can be studied in humans in vivo by using high-frequency intraluminal ultrasound much more precisely than has previously been possible. Achalasia, diffuse esophageal spasm, and nutcracker esophagus are associated with hypertrophy of circular and longitudinal muscle layers. Finally, high-frequency intraluminal ultrasound imaging is the only technique that can detect reflux-related distention of the esophagus and its role in esophageal symptoms. Future approaches to display and quantify ultrasound image data are discussed. The principles of high-frequency intraluminal ultrasound described here are also applicable to study of the motor and sensory function of the other regions of the gastrointestinal tract.
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PMID:Sensory and motor function of the esophagus: lessons from ultrasound imaging. 1568 59

Heller myotomy for achalasia is routinely performed laparoscopically. This offers patients significant benefits compared to open surgery. Surgeons, however, are limited in their manipulation and visualization during laparoscopic interventions. Robotic telemanipulation systems were introduced with the objective of alleviating these limitations. The purpose of this study was to demonstrate the efficacy and safety of performing a Heller myotomy with the use of a robotic telemanipulation system. Fourteen patients were operated on with the da Vinci robot system. Robotic system set-up time, per- and postoperative complications, blood loss, operating time and hospital stay were recorded. Follow-up included manometry and symptom score. The robotic system set-up time was 15 min (10-15). Thirteen procedures (13/14: 93%) were completed by laparoscopic surgery. One procedure was converted because of inadequate exposure. One peroperative mucosal perforation was closed laparoscopically. The median blood loss was 10 mL (10-200). Median operating time was 90 min (75-150). Hospitalization ranged from 2 to 8 days (median 3). No complications occurred during a 30-day postoperative period. Dysphagia was relieved in 12/14 patients (86%). Heartburn was present postoperatively in 2/14 patients (14%). Manometry showed a significant decrease in median lower oesophageal sphincter (LOS) pressure from 2.9 preoperatively to 1 kPa postoperatively (P = 0.008). Robot-assisted laparoscopic Heller myotomy was demonstrated to be safe and effective in reducing basal LOS pressure and dysphagia. The results of this study clearly support the feasibility of the use of this system in performing a delicate laparoscopic surgical procedure. The use of a robotic system was experienced as being highly supportive in manipulation and visualization by the surgical team involved.
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PMID:Early experience in robot-assisted laparoscopic Heller myotomy. 1569 42

Catheter based high frequency intraluminal ultrasound (HFIUS) imaging is a powerful tool to study esophageal sensory and motor function and dysfunction in vivo in humans. It has provided a number of important insights into the longitudinal muscle function of the esophagus. Based on the ultrasound images and intraluminal pressure recordings, it is clear that there is synchrony in the timing as well as the amplitude of contraction between the circular and the longitudinal muscle layers of the esophagus in normal subjects. On the other hand, in patients with spastic disorders of the esophagus, there is an asynchrony of contraction related to the timing and amplitude of contraction of the two muscle layers during peristalsis. Achalasia, diffuse esophageal spasm, and nutcracker esophagus (spastic motor disorders of the esophagus) are associated with hypertrophy of the circular as well as longitudinal muscle layers. A sustained contraction of the longitudinal muscle of the esophagus is temporally related to chest pain and heartburn and may very well be the cause of symptoms. Longitudinal muscle function of the esophagus can be studied in vivo in humans using dynamic ultrasound imaging. Longitudinal muscle dysfunction appears to be important in the motor and sensory disorders of the esophagus.
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PMID:Motor and sensory function of the esophagus: revelations through ultrasound imaging. 1575 58

Pneumatic balloon dilatation is the treatment of choice for esophageal achalasia. Rigiflex (Microvasive, Watertown, MA) polyethylene balloon dilators have been used with varying success and complications. The aim of this study was to evaluate the efficacy of graded balloon dilatation, to achieve symptomatic improvement in patients with achalasia. From January 1987 until the end of December 2003, 300 patients were evaluated and treated for achalasia, with 30 mm balloons. Patients who did not achieve satisfactory symptomatic responses during follow up underwent repeat dilatation with 35-mm balloons. They were studied at the onset then at 1 and 6 month intervals and then yearly for postdilatation symptom evaluation for dysphagia, regurgitation, night cough and heartburn. Baseline and 5-min postdilatation barium swallow studies were obtained to compare barium height and width for efficacy of dilatation and to evaluate for complications. No patients developed cancer of the esophagus in 16 years follow up. Barium height, width, composite symptom score and weight improved significantly during follow up. Two patients, who needed repeat dilatation with 35-mm balloons, developed esophageal perforation; one was successfully managed with intensive medical care management, whereas the other patient died despite surgical intervention. The authors conclude that pneumatic balloon (Rigiflex) dilatation for achalasia of the esophagus is a successful first option, when applied in an incremental balloon size to achieve desired results in symptomatic relief.
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PMID:Sixteen years follow up of achalasia: a prospective study of graded dilatation using Rigiflex balloon. 1577 41


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