Ana V. Martin

Prevalence of respiratory symptoms in patients with achalasia

Achalasia is a primary esophageal motor disorder that results in poor clearance of the esophagus. Although an esophagus filled with debris and undigested food should put these patients at risk for aspiration, the frequency with which the latter occurs has never been documented. In this study, we sought to determine the incidence of respiratory symptoms and complaints in patients with achalasia. A comprehensive symptom questionnaire was administered to 110 patients with achalasia presenting to the Swallowing Center at the University of Washington between 1994 and 2008 as part of their preoperative work-up. Questionnaires were analyzed for the frequency of respiratory complaints in addition to the more typical symptoms of dysphagia, regurgitation, and chest pain. Twenty-two achalasia patients with respiratory symptoms who had also undergone Heller myotomy and completed a post-op follow-up questionnaire were analyzed as a subset. Ninety-five patients (86%) complained of at least daily dysphagia. Fifty-one patients (40%) reported the occurrence of at least one respiratory symptom daily, including cough in 41 patients (37%), aspiration (the sensation of inhaling regurgitated esophagogastric material) in 34 patients (31%), hoarseness in 23 patients (21%), wheezing in 17 patients (15%), shortness of breath in 11 patients (10%), and sore throat in 13 patients (12%). Neither age nor gender differed between those with and those without respiratory symptoms. In the subset of patients with respiratory symptoms who had undergone Heller myotomy, respiratory symptoms improved in the majority after the procedure. Patients with achalasia experience respiratory symptoms with much greater frequency than the approximately 10% that was previously believed. Awareness of this association may be important in the workup and ultimate treatment of patients with this uncommon esophageal disorder.

Synopsis of investigations into proposed theories on the etiology of achalasia.

The current state of research into the etiology of achalasia only allows for speculation. To date, several studies have been performed investigating genetic, immune, and infectious disease mechanisms; however, none of these have been conclusive. Further research into this topic is warranted given the severity of the disease, and it may be possible that all of these mechanisms are involved in the pathophysiology of the disease.

Mo1598 Do Outcomes of Surgical Treatment for Achalasia Depend on the Manometric Subtype

Background: High Resolution Manometry (HRM) yields better understanding of esophageal motility than does conventional manometry, and a new classification system which describes three distinct HRM subtypes of achalasia based on esophageal body contraction patterns appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment with extended Heller myotomy) for each subtype and to identify additional parameters that may predict success of therapy. Methods: From 2008 to 2013 at a single institution 72 patients underwent laparoscopic extended Heller myotomy for first time. In addition to manometric parameters, clinical records were reviewed for symptom duration, patient age at the time of referral, and preoperative esophageal dilation (stage I-III) as assessed by radiography. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within one year after the operation. Long term follow up data (15 to 46 months) was available for a subset of 25 patients in the form of a survey evaluating overall satisfaction with the operation. Results: The 72myotomy patients included 11 with type I (no contractions), 56 with type II (pan-esophageal pressurizations), and 5 with type III (high-amplitude distal spasm). Failure was found in 1 patient with manometric type I and radiologic stage III esophageal dilation, 1 patient with manometric type II and radiologic stage II esophageal dilation, and none with manometric type III. All of the type I patients had at least some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. Treatment failure was not observed in any of the patients under 50 years old (n= 35) nor in any patients with stage I esophageal dilation. Only one of the 25 patients with long term follow up reported dissatisfaction with the treatment result; this patient had type II achalasia on HRM and esophageal dilation was stage I. Conclusions: Overall, laparoscopic extended Heller myotomy is a highly successful treatment for patients with achalasia, and outcomes do not appear to vary significantly according to HRM subtypes. Stage I esophageal dilation and age below 50 may be better indicators of consistent symptom relief after surgical therapy for this disease.