Treatment of achalasia: lessons learned with Chagas’ disease

Abstract

Chagas' disease (CD) is highly prevalent in South America. Brazilian surgeons and gastroenterologists gained valuable experience in the treatment of CD esophagopathy (chagasic achalasia) due to the high number of cases treated. The authors reviewed the lessons learned with the treatment of achalasia by different centers experienced in the treatment of Chagas' disease. Preoperative evaluation, endoscopic treatment (forceful dilatation and botulinum toxin injection), Heller's myotomy, esophagectomy, conservative techniques other than myotomy, and reoperations are discussed in the light of personal experiences and review of International and Brazilian literature. Aspects not frequently adopted by North American and European surgeons are emphasized. The review shows that nonadvanced achalasia is frequently treated by Heller's myotomy. Endoscopic treatment is reserved to limited cases. Treatment for end-stage achalasia is not unanimous. Esophagectomy was a popular treatment in advanced disease; however, the morbidity/mortality associated to the procedure made some authors seek different alternatives, such as Heller's myotomy and cardioplasties. Minimally invasive approach to esophageal resection may change this concept, although few centers perform the procedure routinely.

Non-conventional surgical approach to achalasia: mucosectomy and endomuscular pull-through

“…Neither treatment; however, seems to be ideal since they do not act directly on the physiopathology of the disease [1][2][3][4][5] .…”

Pathogenesis of Achalasia

“…6 또한 Trypanosoma cruzi 에 감염되어 근육신경절이 변성되어 이차성 식도이완불능증이 발생하는데 이를 Chagas병이라고 한다. [7][8][9] 특발성 식도이완불능증에서도 하부식도와 하부식도괄약근의 근육신경절에 존재하는 신경세포가 거의 보이지 않는데, 10 …”

One size fits all: laparoscopic Heller’s myotomy for the treatment of achalasia irrespective of the degree of dilatation

“…Indeed, a shift to LHM to endoscopic dilatation has occurred [17] . LHM is associated to low rates of complications, null mortality, and excellent and long-lasting outcomes superior to 90% of dysphagia relief in most series [18][19][20] . LHM is still the gold-standard treatment for non-advanced achalasia that must be used to compare the outcomes of other treatments such as the newly developed peroral endoscopic myotomy (POEM) [21,22] .…”