SciELO - Scientific Electronic Library Online

 
vol.46 issue2 author indexsubject indexarticles search
Home Pagealphabetic serial listing  

South African Journal of Surgery

On-line version ISSN 2078-5151
Print version ISSN 0038-2361

S. Afr. j. surg. vol.46 n.2 Cape Town May. 2008

 

GENERAL SURGERY

 

Surgical management of achalasia in Zaria, Northern Nigeria

 

 

A. AhmedI; L. M. D. YusufuII; Y. A. UkwenyaII; L. KhalidII; E. S. GarbaI

IF.W.A.C.S.; Division of General Surgery, Ahmadu Bello University Hospital, Zaria, Nigeria
IIF.M.C.S. (NIG.), F.W.A.C.S.Division of General Surgery, Ahmadu Bello University Hospital, Zaria, Nigeria

 

 


SUMMARY

BACKGROUND: Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors.
PATIENTS AND METHODS:
We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome.
RESULTS: There were 47 patients, 31 (66.0%) males and 16 females, mean age (± standard deviation (SD) 34.6±9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4±12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5±8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6±2.5 mm, compared with the postoperative figure of 11.6±1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment.
CONCLUSION: Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.


 

 

“Full text available only in PDF format”

 

 

REFERENCES

1. Orville F, Grima H, Brodi S, Alexander R, Margulis S. Achalasia of the oesophagus. Am J Surg 1970; 100: 198-202.         [ Links ]

2. Yashodhan SK, Shalini K, Amy EBL, et al. Laparoscopic Heller myotomy with Toupet fundoplication. Arch Surg 2005; 140: 827-834.         [ Links ]

3. Gockel I, Bohl JR, Doostkam S, Eckardt VF, Junginger T. Spectrum of histopathological findings in patients with achalasia reflects different aetiologies. J Gastroenterol Hepatol 2006; 21: 727-733.         [ Links ]

4. Kim HJ, Rhee P, Lee SS, et al. Is peristalsis with complete lower oesophageal sphincter relaxation an early stage of classic achalasia? Gastroenterology 2007; 22: 536-541.         [ Links ]

5. Sachdev A, Sandhu BS, D'cruz S, Lehl SS, Agarwal V. Achalasia cardia in mother and son. Indian J Gastroenterol 2004; 23: 109.         [ Links ]

6. Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin North Am 2001; 11: 235-248.         [ Links ]

7. Ho KY, Tay HH, Kang JY. A prospective study of the clinical features, manometric findings, incidence and prevalence of achalasia in Singapore. J Gastrointest Hepatol 1999; 14: 791-795.         [ Links ]

8. Cheng YS, Li MH, Chen WX, Chen NW, Zhuang QX, Shang KZ. Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up. World J Gastorenterol 2003; 9: 2370-2373.         [ Links ]

9. Kostic S, Kjellin A, Ruth M, et al. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia: results of a randomized control trial. World J Surg 2007; 31: 470-478.         [ Links ]

10. Ghosh B, Das SK. Botulinum toxin: a dreaded toxin for use in human beings. J Indian MedAssoc 2002; 100: 607-608.         [ Links ]

11. Vela MF, Ritcher JE, Wachsberger D, Cannor J, Rice TW. Complexities of managing achalasia at a tertiary referral centre: use of pneumatic dilatation, Heller myotomy and botulinum toxin injection. Am J Gastroenterol 2004; 99: 1029-1036.         [ Links ]

12. Lopushinsky SR, Urbach DR. Pneumatic dilatation and surgical myotomy for achalasia. JAMA 2006; 296: 2227-2233.         [ Links ]

13. Onopriev VI, Durleshter VM, Ryabchun VV. Comparative pre- and postoperative results analysis of functional state of the oesophagus assessment in patients with various stages of achalasia. Eur J Cardiothorac Surg 2005; 28; 1-6.         [ Links ]

14. Youssef Y, Richards WO, Sharp K, et al. Relief of dysphagia after laparoscopic Heller myotomy improves long-term quality of life. J Gastrointest Surg 2007; 11; 309-313.         [ Links ]

15. Heller E. Extramukose cardioplastik bein chronischen cardiospasmus mit dilatation des oesophagus. Mitt Grenzgeb Med Chir 1913; 27: 147-149.         [ Links ]

16. Zaaijer JH. Cardiospasm in the aged. Ann Surg 1923; 77: 615-617.         [ Links ]

17. Porziella V, Cesario A, Granone P. Dor fundoplication after myotomy for achalasia: useful, unnecessary, or harmful? J Thorac Cardiovasc Surg 2006; 132: 216-217.         [ Links ]

18. Arvelaskis A, Karavokyros I, Rastounis E. Laparoscopic oesophagomyotomy for achalasia without complementary antireflux procedure. J Laparoendosc Adv Surg Tech 2006; 16: 345-349.         [ Links ]

19. Raiss M, Hrora A, Menfaa M, et al. Heller myotomy without fundoplication: a series of 123 patients. Ann Chir 2002; 127: 771-775.         [ Links ]

20. Ellis FH, Crozier RE, Watkins E. Operation for oesophageal achalasia. Results of oesophagomyotomy without an antireflux operation. J Thorac Cardiovasc Surg 1984; 88: 334-351.         [ Links ]

21. Nmadu PT. Achalasia of the oesophagus. Nig J Surg Sci 1993; 3: 8-11.         [ Links ]

22. Adebo OA, Grillo IA, Osinowo O, Adebonojo SA, Lewis EA. Oesophagotomy for achalasia of the oesophagus. Experience at the University College Hospital Ibadan. East Afr Med J 1980; 57: 390-398.         [ Links ]

23. Mbembati NAA, Lema LEK, Kahamba JF, Mcharo ONM. Operative management of achalasia of the oesophagus. East Afr Med J 1994; 71: 421-423.         [ Links ]

24. Andersson M, Kostic S, Ruth M, et al. Characteristics of timed barium oesophagogram in newly diagnosed idiopathic achalasia: clinical and manometric correlates. Acta Radiol 2007; 48: 2-9.         [ Links ]

25. Eckardt VF, Schmitt T, Kanzler G. Transabdominal ultrasonography in achalasia. Scand J Gastroenterol 2004; 39: 634-637.         [ Links ]

26. Zaninotto G, Annese V, Costantini M, et al. Randomised control trial of botulinum toxin versus laparoscopic Heller myotomy for oesophageal achalasia. Gastroenterology 2004; 127: 1850-1852.         [ Links ]

27. Torquati A, Richards WO, Holzman MD, Sharp KW. Laparoscopic myotomy for achalasia. Predictors of successful outcome after 200 cases. Ann Surg 2006; 243: 587-593.         [ Links ]

28. Gerson LB. Pneumatic dilatation or myotomy for achalasia? Gastroenterology 2007; 132: 811-813.         [ Links ]

29. Garba ES. Achalasia cardia and gastric outlet stenosis in a postmenopausal woman: case report. East Afr Med J 2003; 80: 165-166.         [ Links ]

30. Crookes PF, Corkill S, De Meester TR. Gastroesophageal reflux in achalasia: when is 'reflux' really reflux? Dig Dis Sci 1997; 42: 1354-1361.         [ Links ]

31. Tsiaoussi J, Athanasakis E, Pecchlivanides G, et al. Long-term results after laparoscopic surgery for oesophageal achalasia. Am J Surg 2007; 193: 2631.         [ Links ]