(MEGAESOFAGUL IDIOPATIC)

E. Târcoveanu
• normal, tonusul SEI = 10 cm
H2O;
• marea undã peristalticã
primarã declanşatã de
deglutiţie deschide pasajul
esogastric şi asigurã
evacuarea corpului esofagului.
– chalasia = relaxare
– origine necunoscutã,
– absenţa contracţiilor esofagiene propulsive prin
relaxarea inadecvatã a SEI ca rãspuns la
deglutiţie
– incoordonare motrice cu absenţa relaxarii
sincrone a SEI
• Boala CHAGAS - America de Sud (Trypanosoma Cruzi
distruge plexurile nervoase autonome)
• modificãri anatomo-clinice identice cu cele din achalazie.
• In achalazie:leziuni ale plexurilor nervoase intraumorale din
segmentul terminal al esofagului = plexul Auerbach prezintã
leziuni de distrofie şi sclerozã (aganglionozã cãpãtatã, de
etiologie necunoscutã)
• Autoimună
• Boala Parkinson
• Boli asociate: Hirschprung, osteoartropatia hipertrofică etc.
• Incidenţa - 0,6-2/100.000 locuitori/an.
• 40-60 ani cu uşoarã predominenţã femininã.
• all cases had radiologic confirmation;

 manometry was
performed for 37
patients in group A
and for 11 patients in
Group B.
• presiunea SEI nu scade în timpul
deglutiţiei, înregistrându-se o
încoordonare motrice între sistemul
de evacuare şi sistemul de
propulsie.
• introducerea unui lichid în esofag
declanşeazã o creştere a presiunii
SEI.
• cardiospasm reacţional declanşat
de umplerea esofagianã.
• Patogenic - antagonism intermitent.
• Anatomie patologicã

– tipul I: mai frecvent - achalazie hipotonicã şi

puţin contractilã(esofag cu dilataţie importantã)
– tipul II: achalazie viguroasã (contracţii anormale,
nonperistaltice, produse simultan la diferite
nivele).
Disfagie paradoxală Regurgitaţie Durere

Triada simptomatică
Semne clinice
 DIAGNOSTIC POZITIV

Se pune pe baza semnelor clinice şi mai ales pe

datele oferite de explorãrile paraclinice.
Tranzit baritat
• Manometria
– diferenţiează achalazia de spasmul difuz.
– în formele incipiente are mare valoare diagnosticã.

• Criterii de diagnostic:
 absenţa undei peristaltice primare
 insuficienţa relaxarii SEI dupã deglutiţie
 unde terţiare anarhice fără efect peristaltic

• In achalazia viguroasã, contracţii simultane, ample,

repetitive care apar în mai multe reprize dupã deglutiţie.
• Manometria este
obligatorie.
• Endoscopia
– afirmã natura funcţionalã a
afecţiunii (eliminând un
obstacol tumoral)
– permite depistarea
complicaţiilor
(esofagite, degenerare
malignã)
DIAGNOSTIC DIFERENŢIAL
– sclerodermia (manometrie + EDS)
– stenoze benigne esofag inf.
(peptice, tumorale)
– cancerul esofagului inferior (EDS)
• COMPLICATII:
– infecţii respiratorii recidivante, consecutive
inhalarii alimentelor;
– esofagite acute, rezultatul iritãrii provocate de
stagnarea alimentelor;
– malignizare în 4% din cazuri.
• Tratament:

– Medical
– Endoscopic
– Chirurgical
• Dilatarea pneumaticã

Riscul de perforaţie este de 3% din cazuri

In peste 50% din cazuri rezultatele sunt bune pentru câtiva ani.
• Injectare toxină botulinică în SEI
• Tratamentul chirurgical :
– prima intenţie bolnavilor tineri, celor cu
megaesofag stadiul III, IV,
– bolnavilor cu achalazie asociatã cu hernie
hiatalã
– în caz de eşec al trat. medical/endoscopic

Open Laparoscopic
• Tratamentul chirurgical clasic
– cardiomiotomie extramucoasã -
operaţia Heller
Heller - laparoscopic
• Study groups:
– Group A: conventional open Heller operation
• 43 patients: 24 females and 19 males; mean age 41 yo;
– Group B: laparoscopic Heller myotomy
• 42 patients: 26 females and 16 males; mean age 44 yo;
Miotomia laparoscopică
Miotomia laparoscopică + ghidaj EDS
Miotomia laparoscopică – aspect final
• Surgical approach:
– Group A
• simple myotomy – 20 cases
• myotomy associated with antireflux procedures – 23 cases
(19 Dor and 3 Toupet);
– Group B
• simple myotomy – 12 cases;
• myotomy with Dor fundoplication – 30 cases;
• laparoscopic myotomy as a first therapeutic choice – 30
patients;
• laparoscopic myotomy after failure of forceful pneumatic
dilatation – 12 cases;
• 20 patients had esophageal myotomy under intraoperative
endoscopic guidance;
• Surgical approach - intraoperative accidents:

– Group A
• Perforation – 2 cases (4,65%);
– Group B
• Perforation – 2 cases (4,76%);

Conversion – 1 case (2,3%)

 POSTOPERATIVE EARLY RESULTS

Group A Group B
• Morbidity – 18,4%  Morbidity – 1 case (2,3%)
– 7,8% specific
• Mortality – none  Mortality – none
• Hospital stay - 8,6 day  Hospital stay - 3,5 day
 POSTOPERATIVE FOLLOW-UP
RESULTS
Group A* Group B**
• Clinical, radiological  Clinical, radiological,
manometry
• 3 – 20 years  1 – 20 years

• VISICK I – 30,5%  VISICK I – 61,9% (26 cs)

• VISICK II – 43,4%  VISICK II – 14,2% (6 cs)
• VISICK III – 26,1%  VISICK III – 9,5 (4 cs)
 VISICK IV – 1 case –
recurrence – lap. reinterv.
*NOTED FOR 25 PATIENTS **NOTED FOR 36 PATIENTS
• The first laparoscopic Heller myotomy by Sir
Alfred Cuschieri in 1991
Botulism toxin injection
• Andrews 1999 Surg Endoscopy: similar
decrease in dysphagia score, not durable
– 77% reintervention at 324d
– only 25% conversion to Heller
• Zaninotto 2004 Ann Surg: RCT similar
decrease in dysphagia score, not durable
– 34% symptom free at 2yrs
– 2004 Surgical Endoscopy cheaper at 2yrs
 Pneumatic dilation
• Endoscopic and surgical treatments for achalasia: a
systematic review and meta-analysis
– Article from UCSF by Campos et al who reported an initial
improvement of symptoms in 84.8% of patients after
dilation.
• At 36 months this number had decreased to 58.4%.
• As with BOTOX, subsequent interventions will have
diminishing success rates
 Heller myotomy vs pneumatic dilation
With reported success rates of around 90%, Heller
myotomy has generally been considered to be superior
to dilation

Boeckxstaens GE, et al. NEJM 2011; 364(19):19

To fundoplicate, or not to fundoplicate
that is the question…
• Objective analysis of gastroesophageal reflux
after laparoscopic heller myotomy: an anti-
reflux procedure is required
– Article from Surgical Endoscopy from Jan 2005
– Burpee et al, St. Michael’s Hospital, Univ of
Toronto
• Looked at 50 pts receiving
Heller myotomy without fundoplication
• 30% of pts complained of significant heartburn
• 24 hr pH probe or endoscopy demonstrated
that 60% of pts had significant reflux
• “Objective analysis reveals an unacceptable
rate of gastroesophageal reflux in laparoscopic
Heller myotomy without an antireflux
procedure.
We therefore recommend performing a
concurrent antireflux procedure.”
• Heller myotomy versus Heller myotomy with
Dor fundoplication for achalasia: a prospective
randomized double-blind clinical trial
– 2004 paper from Annals of Surgery by Richards et
al from Vanderbilt
• Prospective, double-blind RCT
• 43 pts enrolled
• Pathologic GER occurred in 10 of 21 patients
(47.6%) after Heller and in 2 of 22 patients
(9.1%) after Heller plus Dor (P = 0.005).
• Manometry and EGD were performed at 6
months post-op.
• No significant difference was observed in surgical
outcome between the 2 techniques with respect
to postoperative lower-esophageal sphincter
pressure or postoperative dysphagia score.
• Endoscopic dilatation may be still being required at
intervals in some patients after myotomy.
IRP (mmHg)
Integrated Relaxation Pressure
Mean EGJ pressure measured
with an electronic equivalent of a
sleeve sensor for 4 contiguous or
non-contiguous seconds of
relaxation in the ten-second
window following deglutitive UES
relaxation.
 Conclusions
• Laparoscopic esophageal myotomy under intraoperative endoscopic guidance became the gold standard in the treatment of achalasia.
• The operation should be performed with limited dissection of the esophagus, as we believe that preserving the support of the posterior
structures around the gastro-esophageal junction is essential to maintain the mechanism of a competent cardia.
 Conclusions
• Laparoscopic Heller myotomy has excellent results
• Should be accompanied by either Dor or Toupet fundoplication (not a Nissen)
• The myotomy should be at least 5 cm on the esophagus to 2 cm on the stomach, and possibly longer
 Conclusions
• Postoperative control should be extended after 4 years of evolution.

• In case of relapse it is preferably by first intention laparoscopic approach and/or endoscopic pneumatic dilatation.