Diagnostic criteria and surgical procedure for megaesophagus - a personal experience

Abstract

Megaesophagus is the end-stage of achalasia cardiae. It is the result of peristaltic disorders and slow decompensation of the muscular layer of the esophagus. The aim of this article is to detail the diagnostic criteria and surgical management of megaesophagus. Criteria were acute bending of esophagus axis; lack of esophagus peristalsis, and no response to stimulation in the manometric test; and Los Angeles C/D esophagitis in the endoscopic examination. Between 1991 and 2004 seven patients (5 females, 2 males; age, 51-67 years; average age, 59 +/- 8 years) were treated. A bypass made from the pedunculated part of the jejunum connecting the part of esophagus above the narrowing with the praepyloric part of the stomach was made. Access was by an abdominal approach. A jejunum bypass was made in six patients with megaesophagus. A transhiatal esophageal resection was carried out, and in the second stage a supplementary esophagus was made from the right half of the colon on the ileocolic vessels in one patient who had experienced two earlier unsuccessful operations. Symptoms of dysphagia, recurrent inflammation of the respiratory tract, and pain subsided in all patients. Complications were not reported in the postoperative period. All patients survived. Subsequent radiographic and endoscopic examination showed very good outcome. The jejunum bypass gave very good results in the surgical treatment of megaesophagus.

Delayed Discovery and Diagnosis of Achalasia Resulting in Megaesophagus in an Elderly Nursing Home Resident

“…Megaesophagus, also termed sigmoid esophagus, results from peristaltic disorders and slow decompensation of the esophageal muscular layer at the end stage of untreated cardiac achalasia . The characteristics of megaesophagus are lack of peristalsis of the esophagus, low intraluminal pressure and lack of response to stimulation, breakdown of the axis of the esophagus, and classification of Los Angeles C/D esophagitis . In addition, dysphagia decreases because the esophagus stretches, but chest pain or discomfort occurs because of greater acid regurgitation, and most individuals lose weight.…”

“…In addition, dysphagia decreases because the esophagus stretches, but chest pain or discomfort occurs because of greater acid regurgitation, and most individuals lose weight. We remind healthcare providers that megaesophagus can be avoided in elderly adults if achalasia is disclosed, diagnosed, and treated appropriately at an early stage . Treatment options include medical methods (e.g., botulinum toxin injection at the lower esophageal sphincter), pneumatic dilatation and surgery (e.g., myotomy with fundoplication, jejunum esophagogastric bypass, laparoscopic Heller myotomy) …”

Esophagectomy for end‐stage achalasia

“…Less dissection is necessary to mobilize and resect only the esophagogastric junction (EGJ) instead of the entire esophagus, but limited resections of the EGJ, when reconstructed via primary esophagogastrostomy, are prone to significant gastroesophageal reflux. For this reason, if a short segment of esophagus is resected, reconstruction is best completed with a sufficiently long interposition of jejunum or colon between the remaining esophagus and stomach . The authors describe low morbidity of the procedures, but the functional disease of the remnant esophagus associated with a slow peristaltic movement of the interposed viscera frequently gives an unsatisfactory alimentary rhythm to oral intake …”

“…Several surgical approaches have been described for esophageal resection in achalasia, including transthoracic (Fig. A), transhiatal (Fig. B), and, more recently, laparoscopic transhiatal (Fig.…”

Endoscopic classifications of esophageal changes in chagasic megaesophagus

“…Chagas disease is caused by infestation with the parasite Trypanosoma cruzi, which can cause a reduction in innervation of the esophageal muscle in patients with megaesophago [2], the end-stage of achalasia cardiae [3]. Of the significant number of complications that patients with achalasia experience, reflux esophagitis is most important [4].…”