Achalasia Cardia: A Comprehensive Review

Abstract

Achalasia cardia is the best characterised oesophageal motility disorder. It is characterised by progressive ganglion cell degeneration in the oesophageal myenteric plexus, which results in impaired lower oesophageal sphincter (LES) relaxation upon swallowing and aperistalsis in the distal smooth muscle segment of the oesophagus. The usual presenting features are dysphagia to both liquids and solids from onset, regurgitation of undigested food, retrosternal pain, heartburn, and weight loss. Initial investigations include upper gastrointestinal (GI) endoscopy and timed barium oesophagogram, whereas high resolution manometry is diagnostic. Therapy in achalasia cardia is directed towards biochemical or mechanical reduction in LES pressures. If candidates are fit for surgery, pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller’s myotomy are the mainstays of therapy that act by mechanical disruption of LES. On the other hand, botulinum toxin and pharmacotherapy (nitrates and calcium channel blockers) act by biochemical reduction of LES and are reserved for surgically unfit patients with limited life expectancy because of their short-lived efficacy. Oesophagectomy is reserved for treating refractory longstanding cases, who have previously failed multiple therapies.

Laparoscopic Heller’s cardiomyotomy for achalasia cardia-a case series with review of literature

“…It has response rate of 90-97% with recurrent dysphagia in 3-10% of patients and GERD can occur in 2-26% of cases. 20 Post-LHM-GERD with extended myotomy can be minimised by concurrent fundoplication (posterior Toupet fundoplication at 270° is a better anti-reflux procedure than anterior Dor fundoplication at 180°). Laparoscopic approach is preferred over the thoracoscopic approach because of shorter operating time and lower probability of conversion to open myotomy.…”

“…LHM has equal efficacy compared to PD with greater sustainability of results in young males. 20 Recently, POEM has emerged as an alternative to LHM. Introduced in 2008, this technique is a new minimally invasive therapeutic endoscopic surgical technique that is especially suitable for patients with type III AC.…”

“…22 An overview of currently available and practiced therapeutic modalities for AC is summarized (Table 3). 20…”

Anaesthetic challenges of achalasia cardia

“…Compression of the left atrium is a rare presenting symptom in patients with dysphagia to both liquids and solids, regurgitation, retrosternal chest discomfort, and heartburn caused by the accumulation of undigested food particles in the oesophagus [1] . Aspiration pneumonia accounts for about 10% of individuals presenting with cough and fever [2] . Achalasia cardia has also been discovered in a few patients during accidental discovery during general anaesthesia induction [3] .…”