Cases reported "Esophageal Achalasia"

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1/46. esophageal achalasia in pregnancy.

    Achalasia is rare motor disorder of esophageal smooth muscle. It has been linked to malnutrition during pregnancy leading to maternal and fetal mortality. We report a case of achalasia with intrauterine fetal death who succeeded in following pregnancy with good fetal and maternal outcome after operative treatment. A 34-year-old pregnant woman had intrauterine fetal death at 27 gestational weeks due to severe and persistent maternal malnutrition during pregnancy. Achalasia was diagnosed postpartum and myotomy-fundoplasty was performed. She succeeded in normal delivery with a healthy baby 21 months after the operation. This case suggests the effect of severe achalasia of early onset on poor fetal outcome, and the efficacy of surgical myotomy for the improvement of following pregnant outcome.
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2/46. Laparoscopic esophagomyotomy with dor anterior fundoplication in a child with achalasia.

    Laparoscopic myotomy with anterior fundoplication was successfully performed on a 12-year-old boy with esophageal achalasia. After completion of a longitudinal esophagocardiomyotomy approximately 6 cm in length, a 180 degrees fundic patch was sutured anteriorly to the myotomized esophagus according to the Dor-Gavriliu technique. The patient showed a rapid and uneventful recovery with complete resolution of his preoperative symptoms. The nonobstructive antireflux procedure can be safely performed concomitantly with another surgery, even in a pediatric patient.
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3/46. Pseudoachalasia as a result of metastatic cervical cancer.

    BACKGROUND: Distinguishing achalasia from pseudoachalasia can be difficult, as the clinical, radiological, and manometric findings can be similar to those seen in achalasia. The features that may differentiate achalasia from pseudoachalasia are reviewed and the pathogenesis of pseudoachalasia is discussed. methods: A patient presented with a clinical scenario of achalasia that was documented by radiographic, endoscopic, and manometric studies. Her past medical history was significant for cervical cancer. Although brief improvement in symptoms was achieved with botulinum toxin injections and esophageal dilation, she had continued progression of symptoms. This direct involvement of the esophagus by a tumor was not demonstrated by any of the routine preoperative studies. RESULTS: At the time of surgery, extensive involvement of the diaphragm, esophagus, and pericardium by a tumor was noted. Pathologic analysis of the tumor was consistent with metastatic cervical cancer CONCLUSION: Pseudoachalasia has been known to occur in response to both benign and malignant causes. Differentiating between pseudoachalasia and achalasia is often difficult because of the similarities. As in this case, the diagnosis of pseudoachalasia may be made by surgical exploration.
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ranking = 1
keywords = operative
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4/46. Laparoscopic approach for esophageal achalasia with epiphrenic diverticulum.

    We report the case of a 65-year-old woman with a 10-year history of dysphagia, regurgitation, cough, and 10-kg weight loss caused by an epiphrenic diverticulum associated with esophageal achalasia managed with a laparoscopic approach. A preoperative barium swallow showed a dilated sigmoid esophagus with a 6-cm epiphrenic diverticulum. Esophageal manometry confirmed the absence of peristalsis in the esophageal body. We performed a laparoscopic diverticulectomy and a 7-cm distal esophageal myotomy with a Dor fundoplication. The postoperative course was uneventful. On the third postoperative day a barium swallow showed no leak, and the patient started oral intake. She was discharged home 5 days after the operation free of symptoms and tolerating a soft diet. Sixteen months after surgery, she was asymptomatic and had gained 8 kg. A barium swallow showed a normal-size esophagus with regular emptying. We reaffirm the feasibility, safety, and efficacy of the laparoscopic diverticulectomy and distal myotomy with Dor fundoplication to manage epiphrenic diverticula resulting from esophageal achalasia.
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keywords = operative
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5/46. Three-dimensional pressure imaging: a novel method for intraoperative manometry during laparoscopic esophagomyotomy for esophageal achalasia.

    With the introduction of computerized manometry, the creation of the three-dimensional (3-D) pressure image with measurement of pressure vector volume (PVV) has become available to assess the pressure structure of the high-pressure zone (HPZ) of the distal esophagus. We have applied this technique to intraoperative manometry during laparoscopic surgery for esophageal achalasia (EA). A laparoscopic esophagomyotomy with anterior fundoplication was performed in a 12-year-old boy with EA. Computerized 3-D images were obtained by a stepwise pullback of a manometric assembly with eight radial side-holes to quantitate the PVV of the HPZ of the distal esophagus in each stage of the operation for EA. Virtual abolishment of the peak pressure image and a marked reduction in the PVV after esophagomyotomy suggested appropriate decompression of the HPZ. Intraoperative manometry using computerized 3-D pressure imaging with measurement of the PVV is thus useful to assess the HPZ during laparoscopic surgery for EA.
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ranking = 6
keywords = operative
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6/46. Laparoscopic esophagogastrostomy: an alternative minimally invasive treatment for achalasia stage III.

    BACKGROUND: The surgical treatment for stage III achalasia with markedly dilated and sigmoid-shaped esophagus is a matter of controversy. Some authors recommend esophagectomy as the primary treatment because they believe that Heller myotomy cannot improve dysphagia in such cases. We present a patient with achalasia stage III in whom we successfully performed a laparoscopic esophagogastrostomy with posterior semifundoplication. methods: Using a five-trocar technique, the esophagogastric junction and the distal esophagus up to the tracheal bifurcation were dissected. An endoscopic stapler (Endo-GIA II) was inserted through a small gastrotomy at the cardia, with one branch placed in the gastric fundus and the other, under esophagoscopic control, in the esophagus. By two consecutive stapler applications, a wide side-to-side esophagogastrostomy was created. To prevent gastroesophageal reflux, a posterior semifundoplication was performed. RESULTS: The operation time was 170 min. Oral food intake was started after radiologic control on postoperative day 7. Radiologic study showed rapid passage of the barium meal and no reflux through the gastroesophageal junction. CONCLUSIONS: Laparoscopic esophagogastrostomy with posterior semifundoplication represents an alternative to esophagectomy and laparoscopic Heller-Dor surgery. Because of the wide side-to-side anastomoses, there is no risk of persisting stenosis such as that reported for the Heller operation, and the procedure certainly is less invasive than esophagectomy. As compared with laparoscopic extramucosal myotomy using anterior Dor fundoplication, it presents about the same technical difficulties.
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ranking = 1
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7/46. Congenital cricopharyngeal achalasia: diagnosis and surgical management.

    BACKGROUND: Congenital cricopharyngeal achalasia is a rare condition in which a newborn presents with dysphagia, choking, nasal reflux, and salivation. awareness of this condition is important because simple myotomy of the cricopharyngeus muscle often solves the problem. methods: The diagnosis and the surgical management of cricopharyngeal achalasia were reviewed based on 4 cases experienced over the last 13 years. RESULTS: The severity of the symptoms and the age of onset were dependent on the severity of achalasia. The cine-fluoroscopic swallow is an important diagnostic procedure. Surgery should be performed early enough for infants to learn how to swallow properly. The surgical procedure involves complete myotomy of cricopharyngeus, allowing the submucosa of the esophagus to bulge out in the posterior midline region. Postoperatively, nasopharyngeal reflux may resolve immediately or decrease over several months, depending on the timing of surgical intervention and the patient's ability to learn the act of swallowing. CONCLUSIONS: Early surgical intervention for this disease is recommended to achieve early recovery from dysphagia and to establish buccopharyngeal swallowing during the appropriate period of development.
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ranking = 1
keywords = operative
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8/46. Development of achalasia secondary to laparoscopic Nissen fundoplication.

    Dysphagia after laparoscopic Nissen fundoplication (LNF) is commonly attributed to edema and/or improperly constructed wraps, and in some instances the cause can be difficult to identify. We report, for the first time, the development of secondary achalasia after LNF as a cause of late-onset postoperative dysphagia. A total of 250 consecutive patients undergoing LNF were analyzed for the development of postoperative dysphagia at a university hospital. patients were considered to have secondary achalasia if they met the following four criteria: (1) preoperative manometry demonstrating normal peristalsis and normal lower esophageal sphincter (LES) relaxation; (2) lack of esophageal peristalsis on postoperative manometry or fluoroscopy with or without incomplete LES relaxation; (3) no mucosal lesions seen on endoscopy; and (4) dysphagia refractory to dilatation. The following three groups of patients were identified: patients who developed secondary achalasia (group A, n = 7); patients with persistent dysphagia requiring and responding to postoperative dilatation (group B, n = 12 patients); and patients whose postoperative recovery was not complicated by dysphagia (group C, n = 231). The groups were comparable in terms of all preoperative variables except for age. patients in group A were older than those in group B (57 years [range 27 to 66 years] vs. 36.5 years [range 27 to 63 years], P = 0.028) but were not significantly older than patients in group C (45 years [range 20 to 84 years], P = 0.42). The onset of severe dysphagia was later in group A than in group B (135 days [range 15 to 300 days] vs. 20 days [range 9 to 70 days], P = 0.002). The median weight loss in group A was also significantly greater than in Group B (15 pounds [range 11 to 44 pounds] vs. 4 pounds [range 0 to 15 pounds], P = 0.0007). Two patients in group A who underwent reoperation failed to improve. Botulinum toxin injections were tried in two patients and Heller myotomy in one with good results. Nine patients in group B improved promptly after one dilatation, and three improved after two dilatations. Secondary achalasia should be considered as one of the causes of persistent dysphagia after an apparently successful antireflux operation. Secondary achalasia tends to occur in older patients and is characterized by a delayed onset of symptoms. Imaging studies are a reliable means of excluding mechanical obstruction as a cause of secondary achalasia, and a negative result should raise the suspicion of secondary achalasia. Esophageal motility studies are necessary to confirm the diagnosis. Failure to consider the diagnosis of secondary achalasia can lead to multiple fruitless attempts at dilatation or even inappropriate reoperations.
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ranking = 7
keywords = operative
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9/46. Achalasia cardia and gastric outlet stenosis in a postmenopausal woman: case report.

    The orderly contractility of the oesophagus and the regulated ability of the pyloric sphincter allow the influx and efflux of gastric contents. When these physiological processes are impaired, gastric luminal transit is altered as expected in achalasia cardia and gastric outlet obstruction. movement across the inlet and outlet of the stomach is therefore altered. A case of a 58-year old woman diagnosed with simultaneous occurrence of achalasia cardia and gastric outlet stenosis resulting from chronic duodenal ulcer is presented. The diagnosis was based on clinical, radiological and intraoperative findings. This patient has remained well after a simultaneous anterior cardiomyotomy and H-M pyloroplasty. To my knowledge this is the first time that such an association causing gastric "inlet" and "outlet" obstruction has been reported.
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ranking = 1
keywords = operative
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10/46. Laparoscopic Heller myotomy with epiphrenic diverticulectomy.

    BACKGROUND AND OBJECTIVES: To describe the technique and results of laparoscopic Heller myotomy and Toupet fundoplication combined with epiphrenic diverticulectomy. CASE REPORT: A 75-year-old man presented to our institution complaining of dysphagia to solid foods and liquids. The preoperative preparation included a barium swallow, esophagoscopy, and esophageal manometry. Three months earlier, the patient had a botulinum toxin injection, which provided temporary relief. Ten months later, the patient underwent a laparoscopic Heller myotomy and Toupet fundoplication combined with an epiphrenic diverticulectomy. RESULTS: No complications occurred. The patient tolerated clear liquids on postoperative day 1; on postoperative day 2, he was discharged tolerating full liquids. He returned to full activity in 1 week. CONCLUSIONS: Epiphrenic diverticulectomy combined with treatment for the underlying motor disorder and gastroesophageal reflux prevention is an accepted practice. We demonstrate that this rare problem can be approached with the laparoscopic technique. Given this favorable result, we plan to continue this technique and establish a longer follow-up and wider series.
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ranking = 3
keywords = operative
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