INTRODUCTION

Achalasia is a motility disorder of the distal esophagus of un- known etiology manometrically characterized by loss of esophageal peristalsis and lack of lower esophageal sphincter (LES) relaxation; with radioscopical proof of aperistalsis, esophageal dilatation with minimum opening of the LES and bird-beak appearance, improper emptying contrast; and endoscopically by dilated esophagus with retained saliva, liquid, and non-digested food in absence of mucous membrane’s stenosis or tumor¹.

Achalasia occurs equally between men and women with an incidence of 1 in 100,000 individuals annually, without racial predilection. The incidence peak presents itself between 30 to 60 years old².

It is of autoimmune, viral, or neurodegenerative etiology; the secondary most frequent cause is Chagas disease, produced by endogenous protozoan Trypanosoma cruzi from South and Central America; this parasite causes long-term autonomic dysfunction of the esophagus’ (and other organs’) intramural neurons, which induce achalasia symptoms².

The main clinical manifestations are: dysphagia in 95% of cases; regurgitation in 75%, chest pain, pyrosis, weight loss and nighttime cough³.

Regarding the diagnosis methods, the ones used are esophageal manometry, dynamic esophagography and upper gas- trointestinal endoscopy (UGE). Esophageal manometry is considered the golden pattern for achalasia diagnosis given the peculiarity of being able to confirm and distinguish be- tween three types of different manometric patterns (Chicago Classification). Type 1 is characterized by minimal esophageal pressurization, type 2 presents panesophageal pressurization, and type 3 is distinguished by secondary spasms to the spastic contractions. In the esophagram, the diagnosis is backed by findings such as esophageal dilation, a gastroesophageal tight junction with bird-beak appearance, aperistalsis and improper emptying contrast. As for upper gastrointestinal endoscopy, the main function is to discard a mechanical obstruction or a pseudoachalasia, given that they can emulate clinical as well as manometrical achalasia⁴.

Achalasia treatment continues to be palliative and is aimed towards functional and symptomatic relief through the slit of the lower esophageal sphincter⁵.

Amongst the therapeutic options, the laparoscopic approach has proven to be a safe, replicable, and effective technique that achieves control over the symptoms with minimal morbility⁶.

The objective of the present study is to prove the experience in the videolaparoscopic handling of the esophageal achalasia in the Hospital Nacional de Itauguá.

METHODS

Observational, descriptive, cross-sectional, retrospective study on patients who attended the general surgery service of the Hospital Nacional de Itauguá during the period between March 2017 and March 2021 (4 years). Adult patients (18 years old and above) from both genders with completed forms were included, with an esophageal achalasia diagnosis through at least one of these three methods: esophagram, esophageal endoscopy and/ or manometry, and those who were submitted to videolaparoscopic surgical treatment during the study’s duration. Patients with an achalasia diagnosis who received medical or endoscopic pneumatic dilation treatment; or an open approach surgical treatment were excluded. For the recollection of data, a data instrument was designed where all variables were included, and the data was obtained through the studied patients’ medical forms. The data was anonymously registered within the Micro- soft Office Excel 2010® program and summarized according to the nature of the variables.

RESULTS

31 patients were included, from which 15 were men (48,39%) and 16 were women (51,61%). The average age was 54,19 years old, with a 22 to 85 years-old range.

The main cause of consultation was dysphagia in 87,1% of patients, followed by regurgitation in 6,4%; vomiting in 3,2%, and sternal pain in 3,2% (See Graphic 1).

The city of origin of the patients was of 29% from Asunción, 22.58% from Alto Paraná, 13% from Cordillera, 9.67% from Caaguazú, among others (See Graphic 2).

Esophageal achalasia diagnosis was performed most fre- quently through upper gastrointestinal endoscopy with an esophagram (n=17), followed by a least frequent upper gastrointestinal endoscopy, esophagram, and manometry (n=6). Esoph- ageal manometry was only able to be performed in 10 patients (See Graphic 3).

Of the 23 patients with an esophagram, grade II esophageal dilation was recorded in 16 of them (69.5%), grade III esopha- geal dilation in 6 of them (26%), and grade IV in one of them.

As for the surgical technique, the laparoscopic Heller’s car- diomyotomy was performed, and the Dor fundoplication asso- ciated antireflux procedure was done on 22 patients (71%), the Toupet one on 6 (19.3%), and the Nissen one on 3 (9.7%).

The average hospitalization days for each surgical interven- tion before discharge was of 5.22 days, with a range between 2 to 22 days, most of them being dedicated to finishing diagnosis studies. No mortality was registered.

Graphic 1.  Cause of consultation for laparoscopy-intervened patients with achalasia. 

Graphic 2.  Patient distribution according to city of origin. 

Graphic 3.  Utilized methods for esophageal achalasia diagnosis. Ref.: UGE: upper gastrointestinal endoscopy. 

DISCUSSION

Achalasia is a motility disorder of the distal esophagus, whose main symptom is dysphagia. It occurs equally between men and women. There is no racial predilection. The incidence peak presents itself between 30 to 60 years old.

There were no significative differences in regards to gender in the present study, whereas the average age was of 54.19 years old. In a study performed in our country in 2014, Cabral et at observed that the average age was of 57±10 years old, figure slightly higher than the one found in this study⁷.

The main cause of consultation was dysphagia followed by regurgitation, and vomiting and sternal pain in lesser occasions, data that matches a published work by Méndez-Sánchez from Mexico in 2018, where the most common clinical manifestation was dysphagia for solids followed by the one for liquids².

More than half of the patients were from Asunción y Alto Paraná, although patients from almost every department of the western region were present.

The diagnosis of said pathology was more frequently per- formed by UGE and esophagram. UGE was performed in all patients (100%), esophagram in 23 (74.2%), and manometry in 10 (32.3%). In a Paraguayan study published in 2016, the main diagnosis methods were chest x-ray and esophagram in 100% of patients, and UGE in less quantity⁸.

This reflects the current systematic use of UGE and the pro- gressive increase of esophageal manometry as a diagnosis meth- od, although performed in less than a third of the patients. Being manometry the gold standard, this figure represents a limitation of the present study.

An esophageal dilation by esophagram was recorded in all patients, with grade II having the most frequency (69.5%). In their thesis, González Paredes showed that the greater percentage of patients were diagnosed in late-stage achalasia according to the esophagram: Grade II in 33%, Grade III in 5%, and Grade IV in 24% which matches with the findings of the present work.9 The surgical technique performed was laparoscopic Heller’s cardiomyotomy, plus the Dor antireflux procedure on 22 pa- tients (71%) which matches with a published work in our country done by the Instituto de Previsión Social on 2022, where the same technique was performed on 61% of patients¹⁰.

The average hospitalization days for said surgical interventions before discharge were of 5.22 days. In the work done by Ramírez Sotomayor published in 2016, the hospitalization days were of 8.82±6.06 days on average⁸.

The hospitalization days remain very high, due mainly to the delay of diagnosis studies.

As bias of the present study, due partially to the low esophageal manometry usage rate, are the systematic lack of Chagas’ tests in an endemic country such as Paraguay, even though they were performed, it wasn’t studied in every case. It would be interesting to develop protocols to define the necessary diagnosis methods for esophageal achalasia. Another limitation of the study was the lack of long-term follow-ups, most likely due to the patients being from very distant areas to the Hospital Nacional de Itauguá.

CONCLUSION

In the present study a clear gender predilection was not found. The average age was of 54.19 years old.

The main cause of consultation was dysphagia in 87.1% of patients followed by regurgitation, vomiting and sternal pain.

The city of origin of the patients were nearly all the oriental region’s departments of Paraguay.

As diagnosis studies, UGE was performed on 100% of the patients, esophagram in 74.2% (mostly grade II), and manome- try in only 32.2%.

The performed surgical technique was laparoscopic Heller’s cardiomyotomy, most frequently done alongside Dor fundoplication (71%). Toupet and Nissen fundoplication were also per- formed.

The preoperative hospitalization average was high due to de- lays on diagnosis studies. No mortality recorded.