Specialty

achalasia

Doctor:

Octavio Rojas Diaz

Specialty

Gastrosurgeon / Achalasia

Address

Av. Coyoacan 715

Cp 03100 Col Del Valle CDMX

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Find the solution to Achalasia with Gastrosurgeon Octavio Rojas in CDMX, Col del Valle

Achalasia is a rare disorder of the esophagus that causes difficulty swallowing solids and liquids. This is believed to be due to the lower esophageal sphincter not relaxing properly and the body not making the necessary peristaltic movements. Fortunately, significant advances have been made in understanding the pathophysiology of this disease and available treatment options, particularly in the field of endoscopy. Some of the more common treatment options include botulinum toxin injection into the lower esophageal sphincter and laparoscopic surgery.

Dr. Octavio Rojas Díaz FACS examines the pathophysiology and symptoms of achalasia, as well as the treatment options available. Botulinum toxin injection has become an attractive alternative to other more invasive treatments, as it is less expensive and has fewer complications. Achalasia has been the subject of study for several centuries due to its unique clinical presentation and pathophysiology, and this review aims to update the most important advances in this field. In summary, achalasia is a disorder of the esophagus that can be successfully treated using various modern therapeutic options.

Pathophysiology and Etiopathogenesis

Achalasia occurs when the lower esophageal sphincter does not relax adequately, causing a functional obstruction to the passage of swallowed material. Also, there is a lack of peristalsis in the body of the esophagus. This results in a double obstruction in patients with achalasia: a distal obstruction due to lack of relaxation of the lower sphincter and a loss of proximal esophageal activity.

In recent years, much progress has been made in understanding the pathophysiology of this disease. The lower esophageal sphincter is controlled by the myenteric plexus, a bundle of nerves that receives signals from the central and local nervous systems, integrating them and commanding the muscle to contract or relax in a physiological and appropriate manner. To accomplish this, neurons in the myenteric plexus produce a variety of neurotransmitters with different effects. In simple terms, net sphincter tone is the result of a balance between excitatory and inhibitory neurotransmitters.

What happens to the LES in achalasia?

In patients with achalasia, a significant decrease in neurons in the myenteric plexus of the esophagus has been found, as well as a mononuclear inflammatory infiltrate. Selective loss of inhibitory motor neurons is observed, leading to excitation of the lower esophageal sphincter (LES) via the cholinergic system unopposed by the inhibitory system. Furthermore, motility disorders in other parts of the digestive tract suggest that the underlying neuronal disorder may be generalized.

The etiology of achalasia is considered a "nitrinergic neuronitis" of the esophagus, with an inflammatory process that predominantly affects the nitrinergic neurons of the myenteric plexus. Although the cause of neuronal degeneration is unknown, recent attention has been paid to the possibility of an autoimmune phenomenon to explain the disease.

A significant proportion of achalasia patients have been found to possess antibodies directed against a specific protein found in a subpopulation of neurons of the myenteric plexus, and active investigations are underway to better understand this immune abnormality and its role in the pathogenesis of achalasia. achalasia. There is no known etiologic treatment that can normalize esophageal function.

Presentation and clinical diagnosis

Achalasia is a rare disease with an estimated prevalence of 10 per 10,000 people. It mainly affects middle-aged adults (between 30 and 60 years), although it can occur at any age. Clinical suspicion of achalasia arises when patients present with both liquid and solid dysphagia, suggesting a neuromuscular problem in the esophagus, whereas patients with mechanical esophageal obstruction often complain only of solid food dysphagia.

Most patients with achalasia also experience regurgitation of swallowed food, as well as chest pain, weight loss, and recurrent nocturnal aspiration.

The first studies to be performed in patients with suspected achalasia are a barium swallow or pharyngoesophageal swallow with cine radiography, which show a smooth narrowing ("bird's beak") at the gastroesophageal junction and minimal passage of contrast into the esophageal junction. stomach.

In classic achalasia, the body of the esophagus is atonic, dilated, and often tortuous, whereas in other cases, uncoordinated contractions may be prominent and the diameter of the esophagus may be normal ("vigorous" achalasia).

Manometric evaluation of the esophagus is considered the most accurate diagnostic method. During this examination, the aim is to demonstrate the lack of peristaltic contractions in the body of the esophagus and an incomplete relaxation of the lower esophageal sphincter when swallowing. Although not necessary for diagnosis, other manometric features such as elevated resting pressure in the lower esophageal sphincter may be present.

In any patient with dysphagia, an endoscopy should be performed to rule out the presence of tumors that may mimic achalasia (pseudoachalasia). These cancers can be found in up to 4% of patients presenting with symptoms of achalasia, with adenocarcinoma of the gastroesophageal junction being the most common type. It is essential to perform a thorough evaluation of the gastroesophageal junction during endoscopy, including biopsies if necessary. Endoscopic ultrasound is increasingly useful in the detection of tumor infiltration in the lower esophageal sphincter.

In addition, it is important to consider that achalasia is a low but definite risk factor for squamous cell cancer of the esophagus, especially if untreated. Therefore, annual endoscopic surveillance is recommended in patients with achalasia.

Achalasia Treatment

The therapeutic options available for achalasia are primarily palliative, focusing on reducing lower esophageal sphincter pressure to improve esophageal emptying and alleviate symptoms. Unfortunately, achalasia still does not have a definitive cure.

However, there are various palliative treatments available that are generally effective. The goal of therapy is to reduce LES pressure and relieve symptoms of obstruction, such as dysphagia and regurgitation. There are several ways to accomplish this, including the use of medication, balloon dilation, or surgery.

Pharmacological

There are several therapeutic options to relax the smooth muscle and decrease the resting pressure of the LES in patients with achalasia. Long-acting nitrates, such as isosorbide dinitrate, are one of them. This drug is administered in doses of 5 mg orally or sublingually before meals, or in doses of 20 mg orally every 12 hours in its delayed form.

Similarly, calcium antagonists such as nifedipine are another group of interest and are used in doses of 10 mg orally or sublingually before meals or when chest pain develops. Several studies have shown that these drugs can alleviate symptoms in patients with achalasia.

On the other hand, there are other drugs such as short-acting nitrates, anticholinergics and beta agonists, although they have been less evaluated and there is not enough information to allow their use recommendation in clinical practice. In addition, their effectiveness is limited and unpredictable, and they frequently cause side effects such as headache, facial flushing, and edema. Despite this, these drugs may be useful as temporary agents while more definitive therapy is established.

In summary, although drugs are not the definitive solution for achalasia, their use may be beneficial for the patient while more effective therapeutic options are sought.

Dilatation

The patient received an instrument made from a whale bone, consisting of a small round sponge attached to the tip of the bone. This instrument allowed the sick man to retain food and drink in his throat by pressing down on the esophagus with the bone, opening the hole for food to pass through without being regurgitated.

This method of dilation is still used in many ways to this day, although a pneumatic balloon is now used instead of the whalebone. Dilation is performed to physically relax the LES muscle and its main risk is perforation, which has an incidence of approximately 5%. The procedure is effective in 75% to 85% of patients in relieving symptoms, although a sustained response is more difficult to achieve.

About 25% of patients have a 5-year remission after a single dilation, while up to 50% of patients may require a second or third dilation in the first 5 to 10 years. Currently, the most commonly used dilators are balloons, which are distended abruptly with solution once they are positioned in the LES.

Forced dilation of the cardia is considered the first indication treatment and is effective and safe in achalasia. The age of the patient and the pressure of the LES after dilation are important factors in predicting the efficacy of treatment. The main contraindications for pneumatic dilation are acute cardiorespiratory situations or others that increase its risks and the lack of patient collaboration, but the existence of a hiatal hernia is not a formal contraindication.

Surgery

In 1913, Ernst Heller described the Anterior Myotomy of the LES fibers, which extends 1 cm. into the stomach and several into the esophagus, as an effective and permanent way to control the symptoms of achalasia. Currently, it can be performed through abdominal or thoracic access, and anti-reflux techniques such as 180° anterior or posterior fundoplication, or 270° (Belsey-Mark IV technique) have been shown to improve long-term outcomes. .

Myotomy has proven to be highly effective, with successful initial results in 80-90% of cases, and with the laparoscopic approach, patient acceptance has been simplified and improved, reducing costs and morbidity and mortality.

It is important to note that although myotomy is an appropriate treatment for achalasia, late recurrences in symptoms may be caused by gastroesophageal reflux, especially in patients not undergoing antireflux techniques. Although they cannot totally prevent it, antireflux techniques can reduce the incidence of reflux. Therefore, surgery may be indicated as the first choice in achalasia, with better results and a longer duration to alleviate symptoms.

Although mortality from surgery is very low or non-existent in series that have used endoscopic or laparoscopic surgery, the most frequent and significant complication is gastroesophageal reflux, which frequently causes esophagitis and even peptic stricture. To reduce the incidence of this complication, it is advisable to use antireflux techniques. In our experience, we have obtained excellent results with Myotomy, combined with a 270 degree Toupet antireflux technique.

In advanced cases of achalasia with significant symptoms and that do not respond to other treatments, it may be necessary to perform an esophageal resection with reconstruction. In very old patients and with significant associated diseases that prevent any effective treatment, adequate nutrition can be achieved through a gastrostomy.

BOTOX botulinum toxin

In recent years, the use of botulinum toxin for the treatment of esophageal obstruction symptoms has gained importance. One of the most potent nerve poisons known, this toxin causes decreased release of acetylcholine at nerve endings, temporarily inhibiting the LES and relieving symptoms of achalasia.

In achalasia, the underlying pathophysiological mechanism involves unopposed stimulation of the LES by acetylcholine. Therefore, the use of BoTx to block the secretion of this neurotransmitter and decrease the tone of the LES seems to be an effective solution. BoTx is administered endoscopically, injecting 20-25 units into each quadrant just above the esophagogastric junction.

Approximately three quarters of patients experience partial relief of symptoms one month after treatment, but its effect is temporary and only half of patients experience improvement after one year, even after multiple treatment sessions.

The efficacy of BoTx appears to be greater in older patients, and its simplicity and rarity of side effects make it an attractive option for those patients considered to be at high risk for more invasive procedures. However, like any new therapy, more studies are needed to ensure its long-term efficacy in achalasia.

Although BoTx can be a temporary solution for achalasia symptoms, its use can cause fibrosis, making surgery more difficult for patients who require further treatment. Data from comparative trials with balloon dilation are optimistic and suggest that both methods may be equally effective in the short term.

conclusions

Achalasia is a rare but intriguing motor disorder of the esophagus, the pathophysiology of which has become increasingly understood over time. Although none of the currently available therapies are completely satisfactory, more and more options are being developed to alleviate symptoms.

With greater knowledge of the pathogenesis and etiology of this condition, it is possible that one day doctors will be able to talk about the cure and even the prevention of this disease. Currently, esophageal myotomy in conjunction with a Toupet-type antireflux technique is considered the best treatment option to alleviate symptoms.

We have obtained excellent results with this modality using a laparoscopic approach, with amazing immediate results, and we have followed patients for more than 10 years. In addition to offering all the advantages already known of the minimally invasive method.

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References

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