Mauricio Ramirez

Changes in the Diagnosis and Treatment of Achalasia

Esophageal achalasia is a primary esophageal motility disorder of unknown origin characterized by the absence of esophageal peristalsis and failure of the lower esophageal sphincter (LES) to relax appropriately in response to swallowing. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with consequent food stasis. The last two decades have seen a significant change in the understanding of the clinical presentation of this disease, and in its diagnosis and treatment.

Esophageal Resection for End-Stage Achalasia

Primary treatment modalities for esophageal achalasia include pneumatic dilatation, per oral endoscopic myotomy (POEM), and laparoscopic Heller myotomy. The same options are available when patients experience post-treatment recurrent dysphagia. However, when these interventions are unsuccessful, and the esophagus becomes dilated and sigmoid in shape, the only remaining option is to perform an esophagectomy.

Clinical Presentation and Diagnostic Evaluation

Esophageal achalasia is a primary esophageal motility disorder defined by lack of esophageal peristalsis and presence of a lower esophageal sphincter (LES) that fails to relax in response to swallowing. In about 50 % of patients, the LES is hypertensive. These abnormalities lead to impaired emptying of food from the esophagus into the stomach with consequent food stasis. Main symptoms are dysphagia, regurgitation of undigested food, aspiration, heartburn, and chest pain. However, since symptoms are frequently non-specific, a proper work-up including upper endoscopy, barium swallow, esophageal manometry and sometimes pH monitoring is necessary to make the diagnosis and provide the most appropriate treatment.

Treatment of Achalasia in Patients with Dilated Esophagus

Some patients with achalasia have a dilated and sometimes sigmoid esophagus. These patients can be divided into two groups: some already have a dilated esophagus at the time of the initial presentation, while others may develop a dilated and sigmoid esophagus after failure of treatment. Treatment must be individualized, using esophageal resection as last resort.

Laparoscopic Heller Myotomy and Fundoplication. What Type

Esophageal achalasia is a primary esophageal motility disorder of unknown origin characterized by lack of esophageal peristalsis and inability of the lower esophageal sphincter (LES) to relax properly in response to swallowing. The goal of treatment is to relieve the functional obstruction caused by the LES, therefore allowing emptying of food into the stomach by gravity. However, the elimination of the LES may be followed by reflux of gastric contents into the aperistaltic esophagus, with slow clearance of the refluxate and the risk of developing esophagitis, strictures, Barrett’s esophagus and even adenocarcinoma [1–4].

Heller Myotomy for Achalasia. From the Thoracoscopic to the Laparoscopic Approach

During the last 25 years, radical changes have occurred in the surgical approach to esophageal achalasia, with a progressive shift from the open to a minimally invasive Heller myotomy. To date, laparoscopic Heller myotomy is considered in most Centers worldwide the procedure of choice with better short-term outcomes and no differences in long-term functional results when compared to open myotomy. The real benefits of the more recently developed approaches, including the laparoscopic single-site approach and the use of the robotic technology, are under evaluation.

Operations for Gastroesophageal Reflux Disease

The patient is a 58-year-old man with idiopathic pulmonary fibrosis (IPF). His pulmonary function tests have become progressively worse over the past 2 years. He has had heartburn and regurgitation for many years, and frequently wakes up at night with fluid in his mouth and coughing. His evaluation included these findings:

Roux-en-Y Gastric Bypass for GERD and Morbid Obesity

The patient is a 33-year-old morbidly obese man with a BMI of 45. Comorbidities include gastroesophageal reflux disease (GERD) with daily heartburn and regurgitation, hypertension, asthma, sleep apnea, and degenerative osteoarthritis. A workup showed the following findings:

Su1751 Symptomatic Relief After Laparoscopic Paraesophageal Hernia (LPEH) Repair

Background: LPEH repair is considered today the standard of care for this condition. While attention has been mostly focused on the incidence of radiologic recurrence, few data are available about the effect of the operation on symptoms. Aims: To determine the effect of LPEH repair on symptoms. Patients and methods: One hundred and sixty two patients underwent LPEH repair in two academic tertiary care centers. Preoperative evaluation included a barium swallow (100%), endoscopy (80%), manometry (81%) and pHmonitoring (25%). Type III PEH was the most common (94%), and it was associated with a gastric volvulus in 26.5%. Results: Average duration of the operation was 147 minutes. Average EBL was 80 cc. A fundoplication was performed in all patients, Nissen in 83%, Dor in 6%, Toupet in 11%, and Collis was performed in 6.1%. Intra-operative complications occurred in 7%. The operation was completed laparoscopically in 97% patients. Four percent of patients had postoperative complications, and three needed a second operation. Table 1 shows the symptomatic evaluation before and after the operation. Average follow-up was 24 months. Conclusions: LPEH repair is safe and effective. Few patients experience postoperative symptoms and these are easily controlled with acid reducing medications. Table 1

An underappreciated cause of intermittent chest pain, asthma, and iron deficiency anaemia

A 74-year-old woman was admitted because of recurrent chest ain and acute asthma exacerbation. She had a history of chest pain hat required 3 Emergency Department visits in the previous 6 onths. Each time, the electrocardiogram and cardiac troponins ere normal. A cardiac work-up, including an angiogram, was lso normal. Laboratory values showed only a mild iron deficiency hypochromic microcytic) anaemia. A retrocardiac gas bubble on hest X-ray (Fig. 1) prompted a barium swallow, which confirmed large paraesophageal hernia (PEH) and intermittent gastric volvuus (Fig. 2). When a patient presents with chest pain, asthma, and iron defiiency anaemia, along with subtle gastrointestinal symptoms, it is ifficult to establish a diagnosis. A thorough clinical assessment is