Kamran Ahmed Malik, Naz F Husain, Asadullah Khan.
Achalasia - A Rare Disease.
J Surg Pak Jan ;6(2):44-5.

Although achalasia is a rare disease with a reported incidence of 1:100,000, it still is the commonest of specific primary esophageal motility disorders. This case report is of a patient admitted in Unit 11, Ward-3, of Jinnah Post-graduate Medical Centre, Karachi. He responded well to a Modified Heller`s cardio-myotomy

A 20 year old male patient was admitted in Surgical Ward 3, JPMC with a three-year history of epigastric pain that was intermittent in character, burning in nature, and mild to moderate in intensity. It was associated with vomiting of partially digested food material. Acid brash and regurgitation were also present. There was however no history of hemetemesis, malena, coughs or weight loss, nor any significant past, personal or family history. The patient was found to be haemodynamically stable with no positive physical findings. Laboratory investigations were within normal limits. Barium Swallow showed a dilated esophagus with a smooth narrowing of the lower segment. Upper G. I. endoscopy then revealed a dilated esophagus filled with fluid, but when the endoscope was passed deeper though the very small gastro-esophageal opening, the remaining examination was normal. Histopathology revealed inflammatory changes at the lower end of the esophagus secondary to reflux esophagitis. Radionucleotide Esophageal Transit Time Scintigraphy depicted a hold up of tracer over the lower two third of dilated esophagus with no appreciable clearance into the stomach, in both standing and lying studies. This was suggestive of a near complete obstruction of the gastro-esophageal junction. The upper esophageal sphincter was found to be normal through esophageal manometery, and the esophagus was seen to be aperistaltic for both dry and wet swallows. Basal tone at the lower esophageal sphincter was between 50-75 mmHg with less than 50% relaxation on swallowing.

After the diagnosis Modified Heller`s esophagocardiomyotomy performed through a midline laparotomy. A single incision was made in the esophagus anteriorly about 4 cm above the thickened muscle, through the longitudinal and circular muscle fibers of the esophagus all the way down to the mucosa that bulged through. Care was taken not to perforate the mucosa during the procedure and no antireflux procedure was performed. A drain was placed in the supra-colic compartment and the abdomen was closed with Prolene #1 in a single layer. The skin closed with 2/0 silk.

Post-operatively the patient showed an uneventful recovery. The drain, containing approximately 200mls of serous fluid on jay one was removed on the 2nd postoperative day, and he was started on clear fluids. On the 10th post-operative day a gastrograffin swallow revealed an improved picture with a significant opening at the gastro-esophageal junction. In a recent followup the patient looked healthier and had no subjective complaint. He was eating well and tolerating his diet.

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