Achalasia: what to do in the face of failures of Heller myotomy.

Achalasia is a primary motility disorder of the esophagus, and while there are several treatment options, there is no consensus regarding them. When therapeutic intervention for achalasia fails, a careful evaluation of the cause of the persistent or recurrent symptoms using upper endoscopy, esophageal manometry, and contrast radiologic studies is required to understand the cause of therapy failure and guide plans for subsequent treatment. Options for reintervention are the same as for primary intervention and include pneumatic dilation, botulinum toxin injection, peroral endoscopic myotomy, or redo esophageal myotomy. When reintervention fails or if the esophagus is not amenable to intervention and the disease is considered end-stage, esophagectomy is the last option to manage recurrent achalasia.

[Treatment of cardiospasm using cardiodilatation technique].

139 patients with achalasia of cardiac orifice among which two third were women and one third--men aged 20-65 years have been observed. 97 patients (69.7%) were treated by cardiodilatation. 17 patients (22.3%) of the main group were treated with pneumocardiodilatation. 44 patients (57.3%) underwent cardiodilatation with the help of pneumo-cardiodilatator improved by the author and electrostimulation. Cardiodilatation technique in a complex treatment of achalasia of cardiac orifice was substantiated by the author.

Laparoscopic esophagomyotomy and antireflux procedure with intraoperative manometry.

We have been routinely performing laparoscopic cholecystectomy and antireflux procedures. Having this experience, we decided to assess the feasibility and safety of performing a laparoscopic esophagomyotomy and antireflux procedure. Here we present a case of a 37-year-old man with a history of progressive dysphagia and a diagnosis of achalasia, made on the basis of clinical, endoscopic, and manometric studies. Preoperative manometry reported a pressure of 52 mm Hg (normal, 15-25 mm Hg) for 4.5 cm (normal, > 3 cm). Laparoscopic esophagomyotomy and anterior fundoplication were performed. The esophagomyotomy included a 6-cm segment of distal esophagus and 2 cm of stomach; postoperative manometry was 18 mm Hg for 3 cm. Eight months postoperatively, a barium swallow demonstrated no reflux. Laparoscopic esophagomyotomy and antireflux procedure can be performed with efficacy and safety, with the advantage of a shorter hospitalization and an early recovery compared with the traditional procedure. Also, we emphasize the importance of the intraoperative manometry in the relevance of a concomitant antireflux procedure.

[Megaesophagus]. / Mégaoesophage.

Although it was first described a long time ago, the pathophysiology of megaesophagus, a primary esophageal motor disorder due to an abnormality of the esophageal sphincter reflex ("achalasia"), remains poorly understood. Our paper shows that it may also be missed clinically for a long time, sometimes for psychological reasons.

Nifedipine for the poor-risk elderly patient with achalasia: objective response demonstrated by solid meal study.

We described an 84-year-old woman with symptomatic achalasia who refused both dilation and surgical treatment. She was treated with the calcium channel blocking drug nifedipine, with significant relief of symptoms. Objective evidence of response to the drug was confirmed by using an egg salad sandwich meal labeled with 99mTc-DTPA.