ACHALASIA AND SURGICAL TREATMENT

Achalasia is the second most common functional disorder of the esophagus requiring surgery after reflux disease.

In achalasia, nerve cells located between the muscle layers of the esophagus are damaged. As a result, the muscles in the esophagus do not contract and the lower esophageal valve opens insufficiency. As the disease duration increases, the esophagus expands.

Although the exact cause is unknown, hereditary, degenerative, autoimmune and infectious factors have been accused.

Achalasia can occur at any age; however, the age of onset is usually between 30-60 years and peaks in the 40s. It is more common in men.

The most common and early symptom of achalasia is difficulty swallowing (dysphagia). Difficulty in swallowing may start suddenly or may be intermittent and repetitive. It becomes continuous in advanced stages. While initially reaching solid foods, it occurs against both solid and liquid foods in advanced stages.

Regurgitation of undigested food occurs in 75% of patients.

Weight loss is seen in 60% of patients.

Chest pain is a complaint seen in approximately 40% of patients in the early stages of the disease. As the esophagus expands, the complaint decreases.

Diagnostic Tests

1. Barium passage x-ray: The esophagus is seen as enlarged. Since the lower lid of the esophagus is not loosened, the esophagus narrows smoothly towards the lower part (bird’s beak appearance). The passage of the contrast agent into the stomach slows down.

2.Gastroscopy/Endoscopy: In endoscopy, the esophagus is seen as wide. Stomach residues can be seen in the esophagus. The lower esophagus cover is not opened by giving air, it is passed to the stomach with the pressure applied by the instrument.

3.Manometry: It is the main test that diagnoses achalasia. It is done to confirm the diagnosis. If achalasia is suspected, a manometry test should be performed even if the passage test and/or endoscopy is normal.

Manometry shows a loss of contraction of the muscles in the esophagus; there is also a loss of relaxation in the lower lid of the esophagus. Esophageal lower valve pressure is high.

The most important disease that can be confused with achalasia is tumors involving the upper part of the stomach. Differentiation of achalasia from gastric cancer is made by endoscopy, endo USG, abdominal USG and tomography.

Treatment

The aim of the treatment is to relieve the complaints by allowing the food in the esophagus to empty into the stomach easily.

The 2 most effective treatment methods are balloon dilation and surgery. (laparoscopic Heller myotomy and partial funduplication). Success results are highest in surgical treatment. With surgical treatment, 85%-100% of swallowing difficulties disappear completely.

Surgical treatment should be applied in patients who do not get an adequate response despite 2 balloon dilatations.

The success rate of balloon dilatation is much less in patients under 40 years of age. Therefore, surgical treatment can be recommended without dilatation in young patients in this group.

In Laparoscopic Heller Myotomy, the muscle fibers in the lower 6 cm of the esophagus and the first 2 cm of the upper part of the stomach are cut and separated. After the surgery, funduplication is performed to prevent gastric reflux.

In high-risk cases for balloon dilatation and surgery, treatment with drugs such as botulinum toxin, nitrates or calcium channel blockers can be applied; but its therapeutic effects are very small.

There is a 3-5% risk of perforation in the esophagus in each applied balloon dilatation procedure.

The success chance of botulinum toxin injection is less than balloon dilatation. It causes scar formation in repetitive applications and complicates the operation.

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