Achalasia (AC) is clinically characterized by chronic intraluminal food stasis and bacterial fermentation, which may contribute to esophageal dysbiosis. This research seeks to analyze the microbiome of individuals with AC, pinpoint significant biomarkers, and explore their relationships with clinical and electrophysiological factors to enhance our comprehension of the mechanisms underlying AC. This study, conducted at a single center, involved 16S rRNA sequencing of esophageal mucosal samples collected from individuals with achalasia and a control group. We assessed microbial diversity, identified distinct taxa using LEfSe, predicted functional capabilities through PICRUSt, and examined the relationship between microbiota and clinical parameters. Biomarkers were identified using a random forest algorithm and subsequently validated through qPCR. Patients with achalasia displayed notable dysbiosis in their esophageal microbiome, marked by changes in community structure while showing no significant shifts in diversity. There was a marked increase in the opportunistic bacterium Fusobacterium, alongside a reduction in beneficial species such as Akkermansia and Ligilactobacillus. The presence of Pseudomonas and Ralstonia was linked to the Eckardt score. The rise in Fusobacterium was further validated through qPCR analysis. Functional predictions suggested an increase in acetyl-CoA biosynthesis among these patients. Notably, levels of Fusobacterium were positively associated with critical clinical indicators, including pressures in the lower and upper esophageal sphincters and the Eckardt score. Esophageal dysbiosis is associated with esophageal hypomotility in achalasia patients.

Allgrove syndrome is an autosomal recessive disease which is characterized by Achalasia, Alacrimia and adrenocorticotropic hormone (ACTH) - resistant adrenal deficiency with progressive neurological manifestations. Allgrove syndrome is caused due to mutations in AAAS gene, localized on chromosome 12q13. This report relates to a 5 years old female child who had complaints of vomiting, fever, cough, hyperpigmentation and poor weight gain. Barium swallow, ophthalmic examination and ACTH stimulation test proves that patient has Allgrove’s syndrome. Management consisted of initiation of cortisone therapy which was successful in improving the hyper pigmentation. Patient was planned for surgical intervention for achalasia cardia on follow-up. Allgrove’s syndrome may be an under diagnosed disorder. High index of suspicion is needed when patients present with such complex symptoms. Diagnosing and timely intervention helps in reducing the morbidity and mortality.

Laparoscopic Heller myotomy with fundoplication in type II esophageal achalasia: A case report.

Laparoscopic Heller myotomy (LHM) is the preferred treatment approach to reducing lower oesophageal sphincter pressure (LOSP). However, less than half of the patients show high LOSP. This study primarily aims to evaluate how LOSP affects operative results. From 2019 to 2023, a total of 52 patients were treated with LHM combined with partial fundoplication, diagnosed by integrated relaxing pressure (IRP) >15 mmHg on high-resolution manometry (HRM). Based on HRM, patients were assigned into two arms: normal LOSP (≤35 mmHg, n = 30) and high LOSP (>35 mmHg, n = 22). Symptoms were assessed preoperatively, and the median duration of follow-up of 24 months using the Eckardt score (ES), the achalasia-specific quality of life (ASQ) score and the SF-36 questionnaire quality of Life (QOL). Treatment failure was defined as ES ≥4 or an ASQ score ≥16. Pre-operative Eckardt and ASQ scores were similar between groups. The high LOSP group had significantly younger populations (≤50 years: 90.90% vs. 60%, P = 0.013). The normal LOSP group had significantly less dysphagia (P = 0.007) and regurgitation (P = 0.011), reflecting significantly lower post-operative ES (0.80 vs. 2.00, P = 0.002). In addition, post-operative ASQ scores (11 vs. 14, P = 0.005) and QOL were significantly better in the normal LOSP group. The high LOSP group experienced a significantly greater failure rate (31.80% vs. 6.7%, P = 0.027). Normal LOSP results in better surgical outcomes and QOL, as younger patients with high LOSP have poorer responses, due to higher LOS muscle tone.

Robotic surgical platforms facilitate accurate dissection with the help of high-definition 3D camera and greater freedom of manoeuvrability of robotic instruments. Aim was to evaluate short-term results (mucosal integrity and hospital stay) and long-term outcomes [symptom improvement and Quality of life (QoL)] of patients undergoing Robotic Heller's Cardiomyotomy (RHC). A retrospective analysis of data collected prospectively of achalasia patients undergoing primary RHC between July 2009 and June 2025. Information collected were demography, Eckardt symptom score (ESS), QoL scores with SF-36, type and stage of achalasia, peri and post-operative data. Sixty-eight patients underwent RHC (33-males). Median age was 46 years (18-82). Median length of myotomy was 8cm (7-11). Median length of hospital stay was 2 days (1-28). One patient had aspiration pneumonia and DVT, and another had a postoperative leak needing emergency surgery. There was no mortality. Median follow-up was 102 months (3- 192). Twenty-one (31%) needed further intervention during follow-up. There was a significant improvement in ESS and in all components of QoL (p < 0.05). RHC can be performed very accurately with a very low leak rate. RHC improves symptoms and quality of life and is an alternative to Laparoscopic Heller's Cardiomyotomy or per-oral endoscopic myotomy (POEM) in the Modern Era.

Robotic surgical platforms facilitate accurate dissection with the help of high-definition 3D camera and greater freedom of manoeuvrability of robotic instruments. Aim was to evaluate short-term results (mucosal integrity and hospital stay) and long-term outcomes [symptom improvement and Quality of life (QoL)] of patients undergoing Robotic Heller's Cardiomyotomy (RHC). A retrospective analysis of data collected prospectively of achalasia patients undergoing primary RHC between July 2009 and June 2025was performed. Information collected were demography, Eckardt symptom score (ESS), QoL scores with SF-36, type andstageof achalasia, peri and post-operative data. Sixty-eight patients underwent RHC (33-males). Median age was 46 years (18-82). Median length of myotomy was 8cm (7-11). Median length of hospital stay was 2 days (1-28). One patient had aspiration pneumonia and DVT, and another had a postoperative leak needing emergency surgery. There was no mortality. Median follow-up was 102 months (3- 192). Twenty-one (31%) needed further intervention during follow-up. There was a significant improvement in ESS and in all components of QoL (p < 0.05). RHC can be performed accurately with a very low leak rate. RHC improves symptoms and quality of life and is an alternative to Laparoscopic Heller's Cardiomyotomy or per-oral endoscopic myotomy (POEM) in the Modern Era.

Peroral endoscopic myotomy (POEM) recently has been reported as minimally invasive therapy for esophageal achalasia requires general anesthesia. Postoperative nausea and vomiting (PONV) is one of the most common adverse events after general anesthesia. Although PONV is associated with adverse consequences undergoing POEM, little has been known about the incidence and risk factors. We evaluated the incidence of PONV undergoing POEM as well as the relationship between incidences and anesthetic agents. This prospective double-blind study comprised 60 patients with American Society of Anesthesiologist physical status I or II who were undergoing POEM with inhaled anesthesia or TIVA. Patients were interviewed by two experienced anesthesiologists about incidence of PONV in accordance with a categorical verbal rating scale (VAS) and PONV Intensity Scale. The primary outcome was the incidence of PONV undergoing POEM between the two groups. In addition, we observed postoperative outcomes including bleeding at surgical site, mucosal injury, and patients’ satisfaction. The incidence of PONV after POEM within first 6 hours was significant lower in the TIVA group than in the sevoflurane group (46.4% vs 76.7%, p=0.025). Additionally, it was observed that number of patients who experienced postoperative complications, such as surgical site injury, mucosal injury, heart burn, pneumoperitoneum, and emphysema, was higher in TIVA group (44.4%) compared with in sevoflurane group (26.7%), but it was insignificant (p=0.130). These data suggest that TIVA could be considered as a good method to prevent PONV during early postoperative period (within 6 hours) after POEM.

Achalasia cardia is a rare condition that leads to dysphagia due to the absence of myenteric cells in the lower esophagus. This condition is diagnosed with barium studies, esophageal manometry, and esophagogastroduodenoscopy. The management of achalasia cardia can be divided into endoscopy therapy, like pneumatic dilatation, and surgical therapy in the form of laparoscopic Heller’s myotomy or Per-oral endoscopic myotomy (POEM). In this review, we will investigate the role pneumatic dilatation, laparoscopic Heller’s myotomy, and Per-oral endoscopic myotomy (POEM) play in the management of achalasia cardia.

The surgical management of achalasia cardia has been evolving over the past decade since the introduction of Heller’s myotomy. Laparoscopic Heller’s myotomy is the current gold standard for the surgical management of achalasia cardia, and it is accompanied by a partial fundoplication. The robotic Heller's myotomy is slowly emerging since the introduction of robotic surgery. The thoracoscopic myotomy is now seldom performed, and esophagectomy is only performed for patients with end-stage achalasia cardia. In this review, we will look at the various surgical operations that are performed for achalasia cardia, looking at the advantages and complications of them.

Background. The esophagogastric junction has a complex anatomical and functional mechanism whose failure is accompanied by the development of hiatal hernia (HН) or esophageal achalasia (EA) requiring surgical correction. Today, in wartime conditions, assessing the quality of life (QOL) and identifying factors contributing to the development of HН and EA are relevant issues in gastroenterology. The aim of the study: to investigate QOL and the impact of trigger factors on the development of HH and EA in war conditions based on questionnaire data. Materials and methods. In the digestive system surgery department, 90 patients were examined between January 2023 and December 2024, of whom 66 were diagnosed with HH and 24 had EA. The control group consisted of 20 healthy individuals. Among the examined patients with HH, there were 49 (74.2 %) men and 17 (25.8 %) women. EA group included 17 (70.8 %) men and 7 (29.2 %) women. The average patients’ age was (47.13 ± 2.81) years. Thirty-nine (43.3 %) patients were military. The general SF-36 questionnaire was used to assess QOL. To study the impact of possible trigger factors on the development of HH and EA, we developed a questionnaire taking into account war factors. Results. It was found that QOL is significantly reduced (p &lt; 0.05) in patients with HH and EA, regardless of status (military serviceman or ordinary citi­zen). Assessment of QOL in the examined patients revealed that the indicators of physical and mental components were lower than those in controls, by 1.6 (p &lt; 0.05) times for both groups. In HH, the indicator of the physical component of health was 1.4 (p &lt; 0.05) times lower than in EA, and the indicator of the mental component of health was 1.7 (p &lt; 0.05) times lower in EA than in HH. When questioned, patients identified possible trigger factors: prolonged and unusually heavy physical exertion (59.1 %) for the development of HH (χ2 = 15.27; p &lt; 0.001) and prolonged stress factor (45.8 %) for the possible development of EA (χ2 = 41.04; p = 0.044). Conclusions. According to the assessment of the QOL in the examined patients during wartime conditions, it was found that the indicator of physical health component was lower in HH than in EA, and the indicator of mental health component was lower in EA than in HH. It was determined that in wartime conditions, the trigger factors contributing to the development of HH were prolonged and unusually heavy physical exertion, and EA might be provoked by an unusual, prolonged stress factor.

ABSTRACTThe enteric nervous system (ENS) is the intrinsic nervous system of the gut and controls essential functions, such as gut motility, intestinal barrier function, and water balance. The ENS displays a complex 3D architecture within the context of the gut and specific transcriptional states needed to control gut homeostasis. During development, the ENS develops from enteric neural progenitor cells (ENPs) that migrate into the gut and differentiate into functionally diverse neuron types. Incorrect ENS development can disrupt ENS function and induce various gut disorders, including the congenital disease Hirschsprung disease, or various other functional gut neurological disorders, such as esophageal achalasia. In this study, we used the zebrafish larval model and performed whole gut spatial genomic analysis (SGA) of the differentiating ENS at cellular resolution. To that end, a pipeline was developed that integrated early and late developmental ENS stages by linking various spatial and transcriptional dimensions to discover regionalized cellular groups and their co‐expression similarity. We identified 3D networks of intact ENS surrounding the gut and predicted cellular connectivity properties based on the stage. Spatial variable genes, such as hoxb5b, hoxa4a, etv1, and ret, were regionalized along gut axes, suggesting they may have a precise spatiotemporal control of ENS development. The application of SGA to ENS development provides new insights into its cellular transcriptional networks and interactions and provides a baseline data set to further advance our understanding of gut neurodevelopmental disorders such as Hirschsprung disease and congenital enteric neuropathies.

ABSTRACTObjectivesPeroral endoscopic myotomy (POEM) is an established treatment for esophageal achalasia. Despite favorable outcomes, the risk of reflux aspiration during general anesthesia induction in POEM remains a concern. This study aimed to identify the risk factors for food residue in the esophagus before POEM and evaluate the necessity of esophagogastroduodenoscopy (EGD) and cleansing the day before POEM.MethodsA retrospective analysis of 61 patients with esophageal achalasia and esophagogastric junction outflow obstruction undergoing POEM between July 2017 and March 2024 was performed. Patients were divided into two groups based on the presence of food residue observed during preoperative EGD: residual (n = 16) and no‐residual (n = 45) food groups. The factors compared included age, sex, Chicago criteria, duration of symptoms, Eckardt score, integrated relaxation pressure, esophageal dilation grade and type on esophagography, and presence of residual food during the initial EGD.ResultsIn univariate analysis, residual food was more common in patients aged <60 years (p < 0.05) and those with higher esophageal dilation grades (p < 0.05). Additionally, residual food during the initial EGD was identified as a significant predictor (p < 0.05).ConclusionsPreoperative EGD and esophageal cleansing the day before POEM may be warranted in patients with initial EGD‐detected residue, younger age, and marked dilation, to reduce reflux aspiration risk and improve procedural safety.

Achalasia is associated with an increased risk of esophageal cancer; though reported incidence rates vary widely (0.4% to 9.2%) due to differences in demographics, follow-up duration, and diagnostic methods. This study evaluates the risk of esophageal cancer and Barrett's esophagus (BE) in achalasia using a large national database and a propensity-matched control cohort. Achalasia patients were identified utilizing the TriNetX database based on International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes for diagnostic procedures and lower esophageal sphincter (LES) directed therapies, including Heller myotomy, peroral endoscopic myotomy, and pneumatic dilation. A matched control group of celiac disease patients was used. A 1-year lead time was applied to exclude secondary malignant achalasia. Outcomes included the incidence of esophageal cancer and BE, with subgroup analysis in patients following therapy. Among 7863 achalasia patients (mean age 58.0, 51.9% female), the esophageal cancer risk was significantly higher than control (risk ratio 2.87, 95% CI: 1.56-5.27, p < 0.001). The absolute risk was low, with 40 cases (0.51%) over a mean follow-up of 3.18 years. BE risk was also higher in achalasia (risk ratio 1.54, 95% CI: 1.24-1.90, p < 0.001), with 220 cases (2.80%). Subgroup analysis revealed no significant difference in BE risk between POEM and Heller myotomy (risk ratio 1.0, 95% CI: 0.42-2.40, p > 0.99). The elevated cancer risk in achalasia over a short follow-up period warrants reconsideration of current endoscopic surveillance guidelines, despite the low absolute risk of esophageal cancer and BE.

Background & Aims: Hysteresis is a change in strain for a given repeated stress; it is a material property of the viscoelastic tissues. We aimed to determine hysteresis of the esophagogastric junction (EGJ) in patients with esophageal achalasia and differences in EGJ hysteresis in different achalasia phenotypes. Methods: In a cross-sectional study design, we measured the change in EGJ distensibility index (DI) with repeated distensions (a marker of hysteresis), and the effects of atropine on the DI using functional lumen imaging probe in 40 patients with esophageal achalasia (types 1, 2 and 3). Results: The DI increased significantly with second distension (hysteresis) as compared to first distension, but not with subsequent ones. Atropine, which ablates active smooth muscle contraction, had no effect on the DI value. Type 1 esophageal achalasia patients and those with severe dilatation (stage III and IV disease) had a higher index DI and lower hysteresis, as compared to esophageal achalasia subtypes 2 and 3. Conclusion: A low DI following atropine suggests that the passive elements (viscoelastic properties) of EGJ are an important cause of low DI in esophageal achalasia. Hysteresis of the EGJ, a material property of the viscoelastic tissue, is different in different achalasia subtypes.

Achalasia cardia may be associated with a risk of severe malnutrition, causing unique challenges in nutritional and definitive management. This study aims to evaluate a novel nutrition strategy in severely malnourished, surgically unfit patients, using percutaneous endoscopic gastrostomy (PEG) tube feeding to improve nutrition followed by per-oral endoscopic myotomy (POEM). We conducted a prospective study of achalasia cardia patients from September 2023 to September 2024 at a tertiary care centre. Patients with severe malnutrition (body mass index [BMI] < 16.0kg/m2) and hypoalbuminemia (< 3.0g/dL) deemed surgically unfit by multidisciplinary team were included. They received PEG feeding to improve nutritional status before undergoing POEM. Serial anthropometric and biochemical parameters before PEG and before POEM were compared and technical and clinical success of both procedures was assessed. Among 45 achalasia patients, eight (17.77%) met the inclusion criteria. The median Eckardt score was 10 (range 9-11), with a median symptom duration of 3.5years (range 2-10). Six patients had type-I and two had type- II achalasia, including two with prior treatment failures. Two patients died even before PEG placement due to severe infections at presentation. The remaining six patients underwent PEG feeding, gaining an average of 11.96 (± 2.68) kg over 11.33 (± 0.94) weeks. This was associated with significant improvement in BMI (13.9 to 19.15; p < 0.00001), albumin (2.8 to 4.2; p < 0.0001), mid-arm circumference (17.27 vs. 22.64; p < 0.001), biceps skin fold thickness (2.15 vs. 3.61; p < 0.001) and triceps skin fold thickness (3.25 vs. 5.84; p < 0.001). All patients then successfully underwent POEM, achieving 100% technical and clinical success. Patients with severe malnutrition (based on BMI and serum albumin) with achalasia considered unfit for POEM or surgery can be managed safely and effectively by using PEG tube feeding as bridge to successful POEM treatment.

Purpose of a study: to evaluate the immediate and remote results of minimally invasive interventions in patients with achalasia cardia.Material and methods. The study included 104 patients with achalasia cardia stage III and IV: 44 men (42.3%), 60 women (57.7%), aged from 20 to 72 years (44.5 (40.0; 64.0)) who underwent peroral endoscopic myotomy (POEM). In order to evaluate the effectiveness of POEM, its effectiveness was compared with data on the immediate and remote results of laparoscopic intervention - esophagocardiofundoplasty (ECFP) (51 patients).Results. The duration of the postoperative period in the group after POEM was on average 3.5 days (47.3%) shorter, the total duration of hospitalization was 4.4 days (42.3%) shorter than in patients after ECFP. Over a period of more than 1 year, the dysphagia index according to the Eckardt scale in patients in the POEM group was 30.7% lower. Recurrence in the group of patients after ECFP was more frequent than after POEM (5 versus 1 (p = 0.021). The gastroesophageal reflux rate was 10.4% lower after POEM, and the reflux rate after POEM was 2 times lower. In the late postoperative periods, the GIQLI questionnaire scores in patients after POEM were significantly better compared to these scores in the group of patients who underwent ECFP.Conclusion. POEM made it possible to significantly reduce both the duration of the postoperative period and the total duration of hospitalization, and complications that occurred in the early postoperative period were milder. The results of patient questionnaires using the Eckardt and GIQLI questionnaires at 6 months and more than 1 year, as well as the recurrence rate of achalasia cardia, indicate the high efficiency of POEM. Further evaluation of the results of minimally invasive interventions in patients with achalasia cardia is necessary.

Post-Laparoscopic Sleeve Gastroplasty (LSG) Achalasia Cardia: A Rare Duo Managed by Peroral Endoscopic Myotomy (POEM)

Background: Esophageal achalasia is a rare motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and food stasis. Surgical interventions, including Heller myotomy with fundoplication or peroral endoscopic myotomy (POEM), effectively alleviate symptoms but induce significant anatomical and functional alterations. In various gastrointestinal surgeries, microbiota have been implicated in modulating clinical outcomes; however, their role in achalasia surgery remains unexplored. Methods: We performed a narrative literature search of various databases to identify studies exploring potential interactions between the gastroesophageal microbiota, achalasia pathophysiology, and surgical treatment, proposing clinical implications and future research avenues. Results: Chronic esophageal stasis in achalasia promotes local dysbiosis by facilitating aberrant bacterial colonization. Surgical restoration of esophageal motility and gastroesophageal transit induces substantial shifts in the microbial ecosystem. Analogous microbiota alterations following procedures such as fundoplication, gastrectomy, and bariatric surgery underscore the significant impact of mechanical modifications on microbial composition. Comprehensive microbiota profiling in patients with achalasia may enable the identification of dysbiotic phenotypes predisposed to complications, thereby providing personalized therapeutic interventions including probiotics, prebiotics, dietary modulation, or targeted antibiotic therapy. These insights hold promise for clinical benefits, including the mitigation of inflammation and infection, monitoring of surgical efficacy through microbial biomarkers, and optimization of postoperative nutritional strategies to reestablish microbial homeostasis, ultimately enhancing patient outcomes beyond conventional treatment paradigms. Conclusions: The gastroesophageal microbiota is a compelling mediator of surgical outcomes in achalasia. Future investigations integrating microbiological and inflammatory profiling are warranted to elucidate the functional role of the gastroesophageal microbiota and assess its potential as a biomarker and therapeutic target.

Gastrointestinal motility is determined by a complex interaction of neuronal, humoral, and cellular-muscular mechanisms that ensure the movement of partially digested food along the gastrointestinal tract, regulate digestion processes, and control sphincter function. This review presents a systematic study of the anatomical and functional organization of the gastrointestinal tract with a special emphasis on peristalsis and coordination of sphincter activity. Particular attention is paid to the structural and functional role of the SIP syncytium, including interstitial cells of Cajal, cells expressing platelet-derived growth factor receptor-α, and smooth muscle cells in the generation of slow waves and intercellular signaling. Important molecules like calcium ions, nitric oxide, and inositol triphosphate, which are crucial for starting and adjusting muscle contractions, are examined. The data on neurohumoral regulation of motility involving such mediators and peptides as acetylcholine, vasoactive intestinal peptide, motilin, cholecystokinin, and glucagon-like peptide-1 are also summarized. The differences in how motility is controlled based on sex and age are examined, particularly how estrogens and nitric oxide signaling affect this. The pathophysiology of central motility disorders, including esophageal achalasia, functional dyspepsia, gastroesophageal reflux disease, and duodenogastric reflux, is studied, considering the role of esophageal hernia. Modern diagnostic methods are considered, including high-precision manometric study, functional lumen assessment technologies, and long-term monitoring of acidity in the esophagus. The pr e sented data emphasize the close relationship between the molecular mechanisms, cellular structure and clinical manifestations of gastrointestinal motility disorders. The study highlights the need for an integrative and interdisciplinary approach to analyzing gastrointestinal motility, which can improve diagnostic accuracy and enable personalized treatment.

Objective. To evaluate the perioperative period and results of peroral endoscopic myotomy (POEM) in patients with achalasia.Material and methods. During the period 2017–2023, POEM was performed in 150 patients aged 15 to 80 years (mean age 53 ± 15,4 years) (94 women, 56 men). The duration of the disease ranged from 6 months to 40 years (mean value 5,8 ± 6,67 years). The average dysphagia value according to the Eckadt scale before surgery was 11.12±0.75.Results. Technical difficulties with tunnel formation due to the presence of fibrosis of varying severity were noted in 24 (16.1 %) patients. The presence of fibrosis resulted in a slight increase in the duration of the intervention at the tunnel formation stage 85.0 (80.0; 120.0) minutes versus 95 (80.0; 120.0) (p=0.87554). Adverse events during the procedure were observed in 5 (3.33 %) patients: no differences were noted between patients with stages II–III and IV of the disease (3 versus 2) (p=0.22). No differences were found in the frequency of complications between patients with or without fibrosis in the submucosal layer (p=0.1922). Oral food and fluid intake were restored in all patients. The Eckadt scale score ranged from 0 to 4 (mean 1.48±0.98). There was no statistically significant difference in the frequency of esophagitis in patients with stages II–III of the disease and stage IV (26 versus 5) (p=0.49).Conclusion. POEM in patients with esophageal achalasia is an effective intervention, regardless of the stage of the disease with a low frequency of intraand postoperative complications. Previous treatment is not a predictor of the occurrence of fibrosis in the submucosal layer, does not affect the frequency of intraoperative complications and does not significantly increase the duration of the intervention. The stage of the disease does not affect the frequency of intraoperative complications and erosive esophagitis.