Achalasia of the esophagus

Achalasia is a rare neuromuscular benign disease of the esophagus. According to statistics, only 1 person out of 100,000 is at risk of developing it.

What happens to the esophagus during illness? When swallowing, a healthy person's cardia (lower esophageal sphincter) opens, and in patients with achalasia, this relaxation reflex disappears. As a result, the propulsive motility of the esophagus is disrupted. As the disease progresses, the organ loses its motor function and stops contracting. In this regard, food does not enter the stomach, but lingers in the esophagus and accumulates there, stretching the walls.

Previously, achalasia of the esophagus was distinguished from achalasia of the cardia, but now there is no such separation. This category also includes the concepts of "diffuse esophagospasm" (Barsoni-Teschendorf disease), "cardiospasm" and "achalasia of the lower esophageal sphincter".

Advantages of treatment of achalasia of the esophagus in EMC

Causes of the disease

Achalasia of the esophagus is considered an idiopathic disease, i.e. it occurs spontaneously. The causes of achalasia of the cardia are still unknown – there are only theories. One of them is that it is associated with trypanosomy (Chagas disease), an infectious disease that is common in South America. At the same time, this theory is not confirmed in the European and North American populations in the eastern regions. Other potential causes of esophageal achalasia are also associated with the presence of infectious agents in the patient (for example, herpes, cytomegalovirus). Among the causes that can also potentially provoke the development of esophageal achalasia are constant stress, autoimmune diseases and a genetic predisposition (that is, the patient may have this disease inborn).

Symptoms of achalasia of the esophagus

Let's list the main symptoms:

1) Dysphagia, swallowing disorder. Paradoxically– sometimes in a patient with achalasia, solid food passes through the esophagus better than liquid food. As a rule, a large amount of liquid consumed helps to alleviate such symptoms. As a result, the contents of the esophagus enter the stomach under water pressure.

2) With achalasia of the cardia, involuntary regurgitation often occurs when the patient regurgitates everything he has eaten or drunk due to its accumulation in the esophagus.

3) Pain syndrome behind the sternum (the middle of the anterior chest wall). Such symptoms make themselves felt already in the initial stages, therefore, achalasia of the esophagus is often confused with angina pectoris. 

4) The fourth and most life–threatening symptom of achalasia is aspiration syndrome, in which acidic stomach contents enter the respiratory tract. As a result, patients develop chronic pneumonia and bronchitis, and many are mistakenly diagnosed with "bronchial asthma" syndrome. Among patients with achalasia of the esophagus, there are cases of death from the effects of aspiration syndrome.

Stages of achalasia development

The traditional classification of the stages of achalasia of the cardia.

Stage I

In the first stage, the esophagus is expanded to 2 cm. Achalasia of the cardia in this case can be treated conservatively.

Stage II

The second stage of achalasia of the cardia is treated with endoscopic balloon dilation. In the second stage, the esophagus is expanded by 2-4 cm.

Stage III

At the third stage, the expansion varies from 4 to 6 cm. It is treated by analogy with the second stage, using balloon dilation. In case of inefficiency by cardiomyotomy.

Stage IV

In patients with terminal achalasia, the esophagus lengthens and bends (S-shaped curvature), its expansion can be more than 6 cm .

The fourth stage requires an esophagectomy (radical surgical treatment with removal of the esophagus and simultaneous plastic surgery of this organ).

Diagnostics

Today, the standard algorithm for diagnosing the disease includes radiography of the esophagus with contrast. This study makes it possible to determine the presence of esophageal dilatation, erosive congestive esophagitis, and accumulation of food masses in the organ. CT is also used to diagnose achalasia and allows not only to identify an enlarged esophagus, but also all the manifestations of aspiration syndrome (chronic pneumonia, food residues in the bronchi, etc.). It is also important to study the patient's medical history.

Esophagomanometry can also be used in the early stages: the study diagnoses a high tone of the lower esophageal sphincter and a high pressure gradient.

Treatment of achalasia of the esophagus

Conservative (medical) treatment of esophageal achalasia is ineffective. At the first stage of the disease, a number of medications can be used, such as calcium channel blockers and nitrates. But they only relieve pain. This is the end of the conservative treatment, then surgical techniques are used to treat achalasia of the cardia.

The instrumental method of esophageal dilation, balloon dilation, is no longer a conservative treatment, nor is botulinum toxin injection (an invasive procedure). Nevertheless, all these are organ–preserving operations that are possible only at stages 1-3. They also include myotomy, which is the dissection of muscles in order to relax them. Also, the POEM method (POEM, endoscopic oral myotomy), which came to us from Japan, is used to treat patients with achalasia of the esophagus.

All of these methods can be used to treat the same patient, and they are approximately the same in terms of effectiveness. Botulinum toxin injections have the most short-term effect. 

It is important to understand that these methods are aimed only at timely emptying of the esophagus: they have a limited effect and cannot cure a person of achalasia. If organ-preserving methods do not give the desired results, at the third stage it is necessary to remove the esophagus and replace it with a plastic prosthesis.

Achalasia operations

Transshiatal subtotal esophagectomy is one of the ways to treat patients with achalasia. This is an operation to remove the esophagus, which, if necessary, can be performed with simultaneous plastic surgery of the gastric tube. This operation at the EMC is performed by Dmitry Valerievich Ruchkin, MD, a surgeon with extensive experience in performing such surgical procedures for esophageal achalasia. The operation is performed in an open manner, without the use of robotic methods and stitching devices. The qualifications and skills of the surgeon in this case are the key to a positive and minimally complicated outcome.

Open operations

Removal of the rectum by open surgery is prescribed in the presence of contraindications (most often for diseases of the heart and lungs). The final decision on the method of surgery is made at an interdisciplinary oncological council of doctors individually for each patient.

Before extirpation, the surgical team examines the anatomy of blood vessels, the location of tumor tissue, and the innate features of blood vessels and nerves. During surgical treatment, this allows you to isolate the layer of the hypogastric plexus and, when resecting part of the colon and removing the neoplasm, do not harm the nerve endings.

At EMC, surgeons have extensive experience in performing nerve-sparing extirpations and have all modern technologies for dissecting (dissecting) the necessary tissues without damage. The surgeon has a Harmonic ultrasonic scalpel in his arsenal, which allows him to isolate tissue structures very subtly and accurately and not harm them. As a result of this approach, the patient will be able to avoid complications in the early postoperative period (urinary disorders, erectile dysfunction, pelvic organ dysfunction).

Complications

Esophagoplasty for achalasia of the cardia is a high-volume and high-risk operation, therefore, postoperative complications often occur after it. Patient c's esophagus is not only removed, but a new one is also formed. Each patient with esophageal achalasia is treated at the EMC by a team of professionals – a surgeon, an anesthesiologist, and a resuscitator. Their well-coordinated work minimizes the risks of surgical treatment.

Rehabilitation after surgical treatment