End-stage Achalasia Research Articles

S484 Outcomes of Esophagectomy in End-Stage Achalasia: A Nationwide Population-Based Study

S484 Outcomes of Esophagectomy in End-Stage Achalasia: A Nationwide Population-Based Study

Current management of pediatric achalasia.

Achalasia is a rare condition affecting esophageal motility in children. In a manner similar to the disease found in the adult population, children experience symptoms of dysphagia, regurgitation, and chest pain due to a failure of relaxation of the lower esophageal sphincter. Standard diagnostic approaches include upper endoscopy and esophageal manometry. New developments in diagnosis include high-resolution esophageal manometry and the endoscopic functional lumen imaging probe. Therapies available include endoscopic balloon dilations and botulinum toxin injections into the lower esophageal sphincter, as well as surgical interventions. The Heller myotomy was first described in 1913; since then, there have been many modifications to the procedure to improve outcomes and lower morbidity. Currently, the most commonly performed surgical procedure is the laparoscopic Heller myotomy, in which the sphincter muscle is divided using longitudinal incisions with or without a partial fundoplication procedure. In recent years, per oral endoscopic myotomy (POEM) is gaining support as a viable natural orifice therapy for achalasia. Complications of POEM occur at a relatively low rate, and outcomes following the procedure have been promising. The treatment of end-stage achalasia however, may include partial or total esophagectomy with reconstruction if possible. Future research is focused primarily on increasing the efficacy, and lowering complications, of existing therapeutic modalities.

An Unexpected Thoracic Finding in a Patient With COVID-19

Question: A 75-year old woman presented to the emergency department with a history of epigastric discomfort and rapidly worsening thoracic pain. She had no fever or cough. On physical examination, she appeared overweight (102 kg, height 162 cm). Laboratory examination revealed normal cardiac troponin levels and slight increase in inflammatory markers (C-reactive protein and neutrophil-lymphocyte ratio). As a nasal screening swab was positive for coronavirus 2019 (COVID-19) infection, she was transferred to the COVID isolation ward. A subsequent computed tomography scan of the chest showed no interstitial lung disease. However, the presence of a monstrous esophageal dilatation with sigmoid shape and dislodgment of the surrounding structures was seen. The esophagus appeared full of solid content compatible with accumulated undigested food residues (Figure A–C). The patient was then referred to our gastroenterology unit. Upper endoscopy was performed under general anesthesia with endotracheal intubation. Endoscopic esophageal findings are shown in Figure D. What is the most likely diagnosis and how should it be managed? Look on page 1112 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The patient was suffering from type II achalasia, which was refractory to previous endoscopic and surgical treatment. In detail, she had undergone three endoscopic pneumatic dilation sessions in 2005 and ultimately laparoscopic Heller-Dor myotomy in 2015. In 2018, an esophageal high-resolution manometry was unsuccessful, probably because the catheter did not reach the stomach in the sigmoid dilated esophagus. We treated our patient with prolonged fasting and nasoesophageal tube placement at 35 cm from the incisors teeth. Multiple daily irrigations with saline solution were performed without apparent benefit. Three endoscopic sessions were then performed to clean the entire esophagus from the huge amount of feces-like food residues. We believe that 2 reasons were behind this ominous presentation. First, the patient suffered from poorly controlled hypothyroidism for which she was taking levothyroxine per os. Laboratory examination revealed high levels of thyrotropin (103 μU/mL) and low levels of free thyroxine (<2.5 pg/mL) and free tri-iodothyronine (1.5 pg/mL). Her severe hypothyroidism was probably due to the inability of oral levothyroxine to reach the stomach, thus decreasing the subjective awareness of her own clinical condition. Second, she was edentulous and this affected the chewing phase, favoring episodes of food impaction and accumulation of food in the esophagus. Surprisingly, she did not experience weight loss and her general nutritional status was good. Achalasia is an uncommon esophageal motility disorder, usually characterized by dysphagia to solids and liquids, chest pain, regurgitation, and weight loss. High-resolution esophageal manometry is the gold standard test for the diagnosis. Diagnostic findings include distal esophageal aperistalsis and integrated relaxation pressure of >15 mm Hg. Achalasia is classified as type 1 classic, type 2 compartmentalized high pressure in esophageal body, and type 3 spastic.1Weusten B.L.A.M. Barret M. Bredenoord A.J. et al.Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.Endoscopy. 2020; 52: 498-515Crossref PubMed Scopus (41) Google Scholar In the last few years, peroral endoscopic myotomy is the most frequent endoscopic intervention for achalasia leading to outcomes that are comparable with those of laparoscopic Heller myotomy. Additional interventions are represented by pneumatic dilation and botulinum toxin injection. Esophagectomy is the last option to manage end-stage achalasia.2Familiari P. Greco S. Volkanovska A. et al.Achalasia: current treatment options.Expert Rev Gastroenterol Hepatol. 2015; 9: 1101-1114Crossref PubMed Scopus (11) Google Scholar,3Hammad A. Lu V.F. Dahiya D.S. et al.Treatment challenges of sigmoid-shaped esophagus and severe achalasia.Ann Med Surg (Lond). 2020; 61: 30-34Crossref PubMed Scopus (5) Google Scholar Peroral endoscopic myotomy was not considered for our patient because of the patent cardia (Figure E), the lack of manometric data, and the poor expected outcome in sigmoid esophagus. She was referred to the endocrinologist for further therapeutic workup. Moreover, dental prosthesis implantation was recommended.

Laparoscopic hand-sewn cardioplasty: an alternative procedure for end-stage achalasia

BackgroundPrimary achalasia is a rare oesophageal motor disorder characterized by the absence of swallow-induced relaxation of the lower oesophageal sphincter and diminished or absent oesophageal body peristalsis. Around 5% of these patients will develop end-stage achalasia, where oesophagectomy may be advocated. We present the laparoscopic hand-sewn cardioplasty as an alternative ‘oesophagus-preserving’ procedure in patients with end-stage achalasia.MethodsWe present a retrospective review of four patients who underwent laparoscopic hand-sewn cardioplasty. Data collected included pre-operative demographic information and investigations; and post-operative outcomes. Patients were scored pre- and post-operatively using Reflux Symptom Index, Eating Assessment Tool-10 and Voice Handicap Index-10 questionnaires.ResultsFour patients underwent laparoscopic hand-sewn cardioplasty during the study period. In one patient, it was performed as a rescue procedure during attempted myotomy following multiple perforations of friable mucosa. In the other three patients, laparoscopic hand-sewn cardioplasty was performed for end-stage achalasia. None of the patients had post-operative complications and all patients were discharged on the second post-operative day. All patients experienced improvement in swallowing symptoms (EAT-10; p = 0.03) but developed post-operative gastroesophageal reflux.ConclusionTo our knowledge, this is the first published case series of laparoscopic hand-sewn cardioplasty for end-stage achalasia. It appears to be a safe and effective procedure for the treatment of end-stage achalasia, offering an alternative minimally invasive procedure to oesophagectomy. Laparoscopic hand-sewn cardioplasty can also be used as a ‘rescue’ procedure during myotomy in patients who have poor-quality mucosa which perforates intra-operatively or is at high risk of perforation/leaking post-operatively.

Mediastinoscopy-assisted Transhiatal Esophagectomy (MATHE) in End-stage Achalasia and Gastric Bypass: Technique and Early Results.

Approximately 5% of patients who have undergone prior Heller myotomy and Roux en Y gastric bypass progress to end-stage achalasia (ESA). Surgical options for ESA are often limited to esophagectomy for management of severe dysphagia or life-threatening aspiration episodes. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) by a small left neck incision combined with an abdominal incision, without using a transthoracic approach, has been reported to reduce pulmonary complications. We herein present the first report of MATHE in 2 consecutive patients with ESA and gastric bypass. Between August 2017 and September 2020, 2 patients who had undergone Heller myotomy and Roux en Y gastric bypass underwent MATHE for ESA. Transhiatal esophagectomy with mediastinoscopy-assisted dissection was performed. The remnant stomach was used as the conduit in both cases. The embedded Supplemental Digital Content 1 (http://links.lww.com/SLE/A269) reports our novel technique. Both cases were completed laparoscopically without conversion to laparotomy or thoracotomy. Median length of hospital stay was 9 days (range, 6 to 11 d). Postoperatively, 1 patient developed a cervical anastomotic leak, which healed with conservative management. No other major complications were observed. MATHE can be safely performed in patients with a history of gastric bypass and ESA without requiring thoracoscopic mobilization of the esophagus. Further studies are required to validate reproducibility of our technique as an alternative to using a thoracic incision.

Quality of Life After Operation for End-Stage Achalasia: Pull-Down Heller-Dor Versus Esophagectomy

Therapy for end-stage achalasia is debated, and data on long-term functional results of myotomy and esophagectomy are lacking. We compared quality of life and objective outcomes after pull-down Heller-Dor and esophagectomy. The study included 32 patients, aged 57 years (interquartile range [IQR], 49-70 years), who underwent the Heller-Dor operation with verticalization of the distal esophagus in case of first instance treatment or failed surgery caused by insufficient myotomy, and 16 patients, aged 58 years (IQR, 49-67 years; P= .806), who underwent esophagectomy after failed surgery for other causes. Data were extracted from a database designed for prospective clinical research. Postoperative dysphagia, reflux symptoms, and endoscopic esophagitis were graded by semiquantitative scales. Quality of life was assessed with the 36-Item Short Form Health Survey questionnaire. The median follow-up period was 68 months (IQR, 40.43-94.48 months) after pull-down Heller-Dor and 61 months (IQR 43.72-181.43 months) after esophagectomy (P= .598). No statistically significant differences were observed for dysphagia (P= .948), reflux symptoms (P= .186), or esophagitis (P= .253). No statistically significant differences were observed in the domains physical functioning (P= .092), bodily pain (P= .075) or general health (P= .453). Significant differences were observed in favor of pull-down Heller-Dor for the domains role physical (100 vs 100, P= .043), role emotional (100 vs 0, P= .002), vitality (90 vs 55, P< .001), mental health (92 vs 68, P= .002), and social functioning (100 v s75, P= .011). The pull-down Heller-Dor achieved objective results similar to those of esophagectomy with a better quality of life. This technique may be the first choice for end-stage achalasia in patients with null or low risk for cancer or after recurrent dysphagia caused by insufficient myotomy.

In the thick of it: peroral endoscopic myotomy with intramuscular tunneling in end-stage achalasia.

In the thick of it: peroral endoscopic myotomy with intramuscular tunneling in end-stage achalasia.

Surgical Treatment of Esophageal Achalasia in the Era of Minimally Invasive Surgery.

Introduction:We have analyzed the short- and long-term results of various surgical therapies for achalasia, especially changes in postoperative esophageal function.Patients and Methods:Between January 1, 2008 and December 31, 2017, 54 patients with esophageal achalasia were treated in our institution. Patients scheduled for surgery underwent a comprehensive gastroenterological assessment pre- and post-surgery. Forty-eight of the elective cases involved a laparoscopic cardiomyotomy with Dor’s semifundoplication, while two cases entailed an esophageal resection with an intrathoracic gastric replacement for end-stage achalasia. Torek’s operation was performed on two patients for iatrogenic esophageal perforation, and two others underwent primary suture repair with Heller–Dor surgery as an emergency procedure. The results of the different surgical treatments, as well as changes in the patients’ pre- and post-operative complaints were evaluated.Results:No intra-operative complications were observed, and no mortalities resulted. During the 12 to 24-month follow-up period, recurrent dysphagia was observed mostly in the spastic group (TIII: 33%; diffuse esophageal spasm: 60%), while its occurrence in the TI type did not change significantly (14.5%–20.8%). As a result of the follow-up of more than two years, good symptom control was achieved in 93.7% of the patients, with only four patients (8.3%) developing postoperative reflux.Conclusions:The laparoscopic Heller–Dor procedure provides satisfactory long-term results with low morbidity. In emergency and advanced cases, traditional surgical procedures are still the recommended therapy.

417 GASTRIC CONDUIT FISTULA AFTER ESOPHAGECTOMY: WHY IT HAPPENS AND HOW TO MANAGE

Abstract Gastric tube fistula is a rare event, but very feared, as it invariably progresses with associated mediastinitis and can be fatal. We present a case in which this fistula occurred together with all diagnostic investigation of etiology and treatment, in addition to a brief review of this complication. Methods A 45-year-old patient underwent minimaly invasive esophagectomy due to end-stage achalasia. After 6 days, she presented acute multivisceral migration to the chest and needed to reintervation by open surgery and hiatoplasty. The patient evolved with outflow of bile through the chest drain. Conservative treatment was attempted. However, after 4 days, she underwent thoracotomy and suture of the orifice, and a nasal tube was maintained to drain the gastric tube. There was no suture dehiscence and in control a seriogram evidenced pyloric stenosis. After 2 months, she was submitted to GPOEM with improvement of gastric emptying and normal return to feeding. Results The risk factors for gastric tube fistula are the same as those for cervical or intrathoracic anastomosis fistula after esophagectomy. Some authors attribute the vascularization of the stomach and malnutrition. However, as shown in this case, impairment of gastric emptying is an important factor to increased pressure and consequent fistula. The patient experienced acute migration through the hiatus, which obstructed the tube for a few hours. And after the defect was corrected, he maintained an increased pressure due to pyloric achalasia, which was initially treated by depressurizing the tube by nasogastric tube and then GPOEM. Conclusion Gastric tube fistula can be avoided when we can establish a good gastric tube emptying condition.

Esophagectomy for end-stage achalasia—is it too aggressive?

Esophagectomy for end-stage achalasia—is it too aggressive?

Diagnosis and treatment of achalasia — a review of foreign literature

Introduction. The interest in achalasia has signifi cantly increased with the advent of new methods for the diagnosis and treatment of this disease. New methods are introduced several years earlier abroad than in Russia, prospective randomized trials are conducted more often, based on the results of which clinical recommendations are established. Therefore, the authors of this article provide an extensive review of foreign literature devoted to the diagnosis and treatment of achalasia, which refl ects not only current trends, but also those areas to which researchers of past years paid attention.Results. Traditional and new diagnostic methods (timed barium swallow and high-resolution manometry) are described. The Chicago classifi cation of esophageal motility disorders version 3.0 is given. The whole spectrum of treatment of esophageal achalasia — conservative and surgical methods with analysis of immediate and long-term results, including the comparison of these methods and with the combined use of several techniques in one patient is presented. The complex problem of choosing a treatment method for the end-stage achalasia is considered. For key points in diagnosing and treating the disease, clinical guidelines on achalasia published in 2020 (European Guideline on Achalasia — UEG and ESNM recommendations) are presented.Conclusion. Esophageal achalasia is a chronic disease, for the treatment of which there is still no consensus. Balloon pneumatic dilation, peroral endoscopic myotomy and laparoscopic Heller myotomy with fundoplication are safe and highly eff ective and can be recommended for the treatment of achalasia. Currently, there is a gradual transition to a less invasive initial treatment of the end-stage achalasia, but large multicenter and randomized clinical trials are necessary to obtain fi nal data on various treatment options.

An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function.

We describe a novel esophagogastric anastomotic technique ("side-to-side: staple line-on-staple line", STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution. The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures. There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p<0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients. The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.

Reoperative surgery for colon conduit failure: a major challenge in esophageal reconstruction

Colon interposition is a second-line reconstructive option after esophagectomy for carcinoma, caustic or peptic lesions refractory to dilatation, perforation or trauma, and end-stage achalasia (1); in other instances, such as prior gastrectomy, necessity of concomitant gastrectomy for syncronous gastric tumors, extensive gastric damage from caustic ingestion, proximal squamous-cell carcinoma, or failures of previous gastric pull-up, the stomach may not be available as a first-choice conduit or an extra-long graft may be required to reach the hypopharynx (2). The most typical colon transplant is a long graft with an upper intrathoracic or neck anastomosis, and location of the anastomosis depends on the route of colon interposition. A retrosternal route and a cervical esophago-colic anastomosis is generally preferred in patients with “hostile” mediastinum from previous thoracotomy or radiotherapy, or as a second-stage “bypass” procedure following emergency esophagectomy or esophageal exclusion and diversion (3). Rarely, when the retrosternal route is not viable due to previous sternotomy, the colonic graft can primarily be placed antesternally through a subcutaneous tunnel.

Unusual achalasic sigmoid esophagus

Achalasia cardia is a rare primary esophageal motility disorder with an incidence of about 1 in 100,000 individuals. If left untreated or inappropriately treated, the disease may progress to end-stage achalasia characterized by megaesophagus or sigmoid esophagus. The presentation as severe malnutrition, anemia, hypoalbuminemia, and asymptomatic tracheal compression has not been described in the setting of the sigmoid esophagus, in absence of underlying malignancy. Here we report an interesting case of a young male, who presented with the above features and managed excellently by open Heller’s myotomy under epidural anesthesia due to the poor performance status.

Quality of Life After Surgery for End-stage Achalasia

Quality of Life After Surgery for End-stage Achalasia

Clinical outcomes following esophagectomy for benign esophageal diseases: a single center experience

Background: Surgery is the treatment option for wide range of benign esophageal diseases. But there are very few studies on Indian population, documenting the profile and clinical outcome of esophageal disease treated by surgical intervention. Hence author undertook a study to determine the clinical outcomes following esophagectomy for benign esophageal diseases.Methods: The current study was a prospective observational study, conducted in Velammal Medical College, Madurai. Data collection was done for 6 years from January 2012 to December 2017. Patients diagnosed with benign esophageal diseases were enrolled. The surgical procedures performed and outcomes were documented. Mean and standard deviation were used to summarize numeric variables, number and percentage were used to summarize categorical variables.Results: A total of 20 cases were included, with 11 men and 9 women. The mean age was 42.6±8.3 years. Dysphagia (90%) was the most common presentation, followed by heart burn (58%), regurgitation (40%) and chest pain (25%). Boerhaave syndrome (25%) was the most common diagnosis followed by foreign body perforation in 2(10%) patients. Corrosive stricture, peptic stricture, perforation following pneumatic dilatation and end stage achalasia were present in 2(10%) patients each. Jejunostomy and pyloroplasty were the procedure done in all cases. Stomach was the conduit used in 90% of patients. The conduit placement was done in the posterior mediastinum. The duration of the hospital stay ranged from 10 to 35 days. Mortality rate was 10%. Pulmonary morbidity (40%) was the most common post-operative complication, followed by wound infection (20%). Anastomotic stricture occurred among 30% of subjects.Conclusions: There is a high probability of occurrence complications following esophagectomy for benign disease. Clinicians must be aware of incidence of various complications, to be able to minimize and manage them effectively.

1778 Too Stubborn to Contract: A Case of End Stage Achalasia Presenting as a Sigmoid Esophagus

INTRODUCTION: Sigmoid esophagus is a form of end stage achalasia characterized by massive dilatation and tortuosity of the esophagus. It is associated with poor response to conventional treatment and poses a significant challenge in the management. We present a case of an elderly female with achalasia who presented with sigmoid esophagus and was not considered a surgical candidate due to comorbidities. CASE DESCRIPTION/METHODS: An 84-year-old female with medical history of achalasia, colon cancer, heart failure and end-stage renal disease, admitted for aspiration pneumonia and respiratory failure requiring mechanical ventilation. Her achalasia was diagnosed three years prior to the presentation and was treated with botulinum toxin injection multiple times. Physical exam showed copious secretions in the oral cavity. Laboratory data showed leukocytosis. Chest CT showed a markedly dilated and tortuous esophagus with 10.2 cm diameter in maximum dimension. Upper endoscopy revealed a dilated and patulous lower esophagus with a tight gastroesophageal junction without any obstructing mass. A large amount of food was noted in the entire esophagus which was removed by a Roth net. Achalasia was considered end stage and the patient was deemed not a candidate for surgical treatment of achalasia in view of the comorbidities. A percutaneous gastrostomy tube was placed. DISCUSSION: Achalasia is an esophageal motility disorder characterized by esophageal aperistalsis and failure of the lower esophageal sphincter to relax during deglutition. Sigmoid esophagus is a severe form of achalasia characterized by a tortuous and massively dilated esophagus more than 6 cm that resembles sigmoid colon. Despite the treatment by the conventional methods like surgical myotomy, pneumatic dilation or botulinum toxin, 5% of the patients may develop an end stage achalasia. Dysphagia, regurgitation and recurrent aspiration pneumonia are the main clinical features. Imaging and esophagogram show dilated esophagus. Endoscopy shows tortuous dilated lumen and friable mucosa with food debris. Manometry is usually not needed to diagnose sigmoid esophagus as the esophagogram and endoscopy are diagnostic. Whereas, Heller’s myotomy is the treatment of choice in achalasia, it is regarded inadequate for the treatment of sigmoid esophagus due to operative difficulty, and esophagectomy is considered as the most appropriate option. However, the esophagectomy is associated with 5-10 % mortality and is not an option for patients with multiple comorbidities.

1729 An Unusual Case of Ventilatory Compromise and Mega-Esophagus

INTRODUCTION: Mega-esophagus, usually due to achalasia or pseudoachalasia, can cause bronchial compression when filled with phytobezoars. We present a case of mega-esophagus not due to achalasia but with profound ventilatory consequences. CASE DESCRIPTION/METHODS: A 67 year old alcoholic man presented with 24 hours of increasing dyspnea at rest. He denied fevers, chills, cough, chest pain, heartburn, dysphagia, abdominal pain or weight loss. On physical exam he was somnolent but arousable. He was able to speak in full sentences. Lungs revealed right sided rhonchi. He was afebrile, BP 211/100, pulse 68, respiratory rate 18, and O2 saturation 80-85% on room air which improved to 94% after 4L nasal O2. Urine toxicology was positive for opiates and cocaine. Chest CT showed a 6.8 cm esophagus filled with debris. It was herniated into the right upper thorax and terminated in a narrow taper at the aortic arch. The trachea deviated rightward and narrowed to 4 mm. The proximal left main-stem bronchus was narrowed to 2 mm. The right upper lobe showed scarring, cystic bronchiectasis, and pleural thickening. On day 2 the patient developed severe dyspnea and orthopnea. O2 saturation varied with position. After intubation and transfer to the ICU for treatment of acute ventilator failure, GI was consulted to decompress the mega-esophagus presumed due to end stage achalasia. EGD initially revealed a dilated esophagus with a phytobezoar. Upon partial clearing two lumens were noted: one containing more food and one which lead to a normal distal esophagus, stomach, and duodenum. The first opening was a large diverticulum located about 20 cm from the incisors and was filled with recently ingested food. Transfer to a tertiary care center was recommended to manage possible total airway collapse. There, repeat chest CT showed a distended esophagus to the level of the aortic arch with no compression of the airways. Esophagram was not consistent with achalasia but demonstrated a large bezoar filled diverticulum. Repeat EGD was done to complete bezoar removal. Patient’s respiratory status normalized. Elective esophagectomy was planned, but the patient was lost to follow up. DISCUSSION: Our patient likely had a traction diverticulum as he gave no antecedent history of heartburn or dysphagia and the food in the bezoar was not fermented. In addition, his distal esophagus appeared normal on barium swallow. This is may be the first reported case of airway compression due to mega-esophagus due to a traction diverticulum.

Revisional Procedures for Recurrent Symptoms After Heller Myotomy and Per-Oral Endoscopic Myotomy.

Background: Achalasia and other esophageal motility disorders are incurable diseases for which palliation and symptom relief are the goals. One of the many ways these diseases are treated is with either a Heller myotomy or, now more commonly, per-oral endoscopic myotomy (POEM). Unfortunately, symptoms persistence or recurrence is common. This review presents our current approach to these complex patients. Methods: Review of the literature pertaining to approaches to recurrent or persistent symptoms after myotomy for esophageal motility disorders and elucidation of our multidisciplinary approach to this patient group. Results: There are a myriad of causes of recurrent or persistent symptoms. These include incomplete myotomy, periesophageal scarring, reflux-induced stricture, obstructing fundoplication, functional dysphagia, and end-stage achalasia. Therapeutic options include redo myotomy (either Heller or POEM), botulinum toxin injection, pneumatic, balloon or Savary dilation, adhesiolysis, and fundoplication reversal or esophagectomy. Choice of approach is best done through multidisciplinary consensus. Conclusions: A multidisciplinary approach to patients with persistent and recurrent symptoms after myotomy can best tailor the therapeutic approach based on symptom causation.

Esophagectomy for End-Stage Achalasia

Treatment for achalasia of cardia is multidirectional nowadays and depends on several factors such as patient’s sex and age, type and stage of disease, co-morbidity and complications. However the treatment for end-stage achalasia is still controversial. Ones who advocate organ preservation surgery consider esophagectomy an ultima ration. These authors conceive that esophagectomy is too traumatic for benign disease with low progression. Esophagectomy as a first approach for end-stage achalasia is recommended by others authors who believe that progredient course of disease (nonreversible strongly dilated and atonic esophagus), debilitating dysphagia, regurgitation, aspiration syndrome and ineffective intervention in cardia make the extirpation of the esophagus necessary. Persistent degeneration of life quality and high possibility of such devastating symptoms as aspiration and esophageal cancer alongside with unacceptable results of myotomy raise questions on the effectiveness of the organ preservation surgery for end-stage achalasia