Diese Längskohortenstudie untersuchte den Langzeitverlauf nach pneumatischer Dilatation mit dem Fokus auf mögliche prädiktive Faktoren.

Background and Aims The evolution of nonspecific esophageal motility disorders remains unclear. The aim of this study was to investigate whether nonspecific esophageal motility disorders progress into specific motility disorders and whether such progression is predictable. Methods Seventy-six symptomatic patients (49 males, 27 females, mean age 57 ± 16 years) with newly diagnosed nonspecific esophageal motility disorders were prospectively registered and followed-up. Follow-up visits, with structured interviews and manometric re-evaluation, were recommended biannually and whenever symptoms exacerbated. Results Forty-three patients were followed for up to 4 years, symptoms worsened in 30% of patients, resolved in 26%, improved in 14% and were unchanged in 30%. Twenty-eight patients agreed to undergo manometric re-evaluation. Fifteen (53.6%) of these patients showed a progression to achalasia. The remaining patients continued to display features of nonspecific esophageal motility disorders (32%) or had normal motility (11%). The only significant association could be determined between age and progression to achalasia reaching nearly 100% in patients’ ≤46 years of age. In contrast, none of the patients’ ≥68 years progressed. Conclusion More than half of the patients in our cohort with nonspecific esophageal motility disorders showed a transition into achalasia. Neither manometric nor clinical findings predicted the progression of nonspecific esophageal motility disorders. However, young patients were more likely to progress to achalasia.

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.

AIM:To study, whether the association of Schatzki rings with other esophageal disorders support one of the theories about its etiology.METHODS:From 1987 until 2007, all patients with newly diagnosed symptomatic Schatzki rings (SRs) were prospectively registered and followed. All of them underwent structured interviews with regards to clinical symptoms, as well as endoscopic and/or radiographic examinations. Endoscopic and radiographic studies determined the presence of an SR and additional morphological abnormalities.RESULTS:One hundred and sixty-seven patients (125 male, 42 female) with a mean age of 57.1 ± 14.6 years were studied. All patients complained of intermittent dysphagia for solid food and 113 (79.6%) patients had a history of food impaction. Patients experienced symptoms for a mean of 4.7 ± 5.2 years before diagnosis. Only in 23.4% of the 64 patients who had endoscopic and/or radiological examinations before their first presentation to our clinic, was the SR previously diagnosed. At presentation, the mean ring diameter was 13.9 ± 4.97 mm. One hundred and sixty-two (97%) patients showed a sliding hiatal hernia. Erosive reflux esophagitis was found in 47 (28.1%) patients. Twenty-six (15.6%) of 167 patients showed single or multiple esophageal webs; five (3.0%) patients exhibited eosinophilic esophagitis; and four (2.4%) had esophageal diverticula. Four (7%) of 57 patients undergoing esophageal manometry had non-specific esophageal motility disorders.CONCLUSION:Schatzki rings are frequently associated with additional esophageal disorders, which support the assumption of a multifactorial etiology. Despite typical symptoms, SRs might be overlooked.

Patients with achalasia have an increased risk for the development of esophageal squamous cell cancer. Endoscopic surveillance in long-standing achalasia has been advocated by some, but the most recent American Society of Gastrointesinal Endoscopy guidelines regard current data as insufficient to support such an approach. In this issue of the American Journal of Gastroenterology, Leeuwenburgh and colleagues report on the results of a long-term prospective study with fixed surveillance intervals. The authors confirm earlier observations of an increased cancer risk after 10 years of symptomatic achalasia. Despite some limitations, this study and earlier data suggest that it might be worthwhile to consider endoscopic surveillance in patients with long-standing achalasia.

The best long-term treatment results for patients with idiopathic achalasia have been achieved with pneumatic dilation or surgical myotomy. A new study adds evidence that good or excellent symptomatic results can be achieved in the long term when pneumatic dilation is used as the primary treatment strategy. In cases of early treatment failure (<2 years), surgery was found to be the best rescue therapy.

This study investigated the long-term clinical course of patients with Schatzki rings, who were treated by single bougie dilation. Furthermore, it analyzed possible predictors for the time of recurrence.

Zhu Q, Liu J, Yang C. Clinical study on combined therapy of botulinum toxin injection and small balloon dilation in patients with esophageal achalasia. Dig Surg 2009; 26: 493 – 498.

Patients with achalasia have an increased risk for the development of esophageal squamous cell cancer. Endoscopic surveillance in long-standing achalasia has been advocated by some, but the most recent American Society of Gastrointesinal Endoscopy guidelines regard current data as insufficient to support such an approach. In this issue of the American Journal of Gastroenterology, Leeuwenburgh and colleagues report on the results of a long-term prospective study with fixed surveillance intervals. The authors confirm earlier observations of an increased cancer risk after 10 years of symptomatic achalasia. Despite some limitations, this study and earlier data suggest that it might be worthwhile to consider endoscopic surveillance in patients with long-standing achalasia.

Einleitung: Der Schatzki Ring ist eine häufige Ursache für Dysphagie und Bolusobstruktion. Die Ösophagusbougierung hat sich als Therapie etabliert, im Verlauf kommt es jedoch häufig zu Rezidiven. Daher wurde der Langzeitverlauf von Patienten nach Dilatation symptomatischer Schatzki-Ringe untersucht. Neben der rezidivfreien Zeit wurde die Häufigkeit von assoziierten ösophagealen Läsionen und deren Einfluss auf die Remissionsdauer analysiert.

Idiopathic achalasia is a rare primary motility disorder of the esophagus. The classical features are incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) and a lack of peristalsis in the tubular esophagus. These motor abnormalities lead to dysphagia, stasis, regurgitation, weight loss, or secondary respiratory complications. Although major strides have been made in understanding the pathogenesis of this rare disorder, including a probable autoimmune mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals, a definite trigger has not been identified. The diagnosis of achalasia is suggested by clinical features and confirmed by further diagnostic tests, such as esophagogastroduodenoscopy (EGD), manometry or barium swallow. These studies are not only used to exclude pseudoachalasia, but also might help to categorize the disease by severity or clinical subtype. Recent advances in diagnostic methods, including high resolution manometry (HRM), might allow prediction of treatment responses. The primary treatments for achieving long-term symptom relief are surgery and endoscopic methods. Although limited high-quality data exist, it appears that laparoscopic Heller myotomy with partial fundoplication is superior to endoscopic methods in achieving long-term relief of symptoms in the majority of patients. However, the current clinical approach to achalasia will depend not only on patients' characteristics and clinical subtypes of the disease, but also on local expertise and patient preferences.

BACKGROUND/AIMS:Previous investigations of esophageal tissue and serum probes failed to identify a common etiologic agent predisposing to, triggering or causing achalasia. In order to further examine the detailed pathologic processes resulting in achalasia we performed electron-microscopic studies of muscle biopsies taken from the LES high pressure zone in patients undergoing surgery--either Heller myotomy or esophageal resection.METHODOLOGY:Smooth muscle biopsies with a 20 x 15-mm longitudinal segment of the myenteric plexus from the distal esophagus (lower border of the esophageal incision) in patients undergoing Heller myotomy for achalasia were taken. In patients with end-stage achalasia and mega-esophagus with esophageal resection, the complete esophageal body was available. For electron microscopy, ultrathin sections were contrasted with uranyl-acetate and plumbic citrate. The photographs were taken by a digitalized electron-microscope (ZEISS, Leo 905).RESULTS:A striking finding was the large number of mast cells in the region of the smooth muscle layers as well as in the surrounding connective tissue and also in close vicinity to the nerve cells and to the nerve fibres. The smooth muscle cells in these regions were very often stained less intensively, and they showed signs of an acute degenerative process.CONCLUSION:Our electron microscopic studies suggest that mast cells may play an important role in the secondary pathogenesis of achalasia. Esophageal retention and bacterial overgrowth with stasis esophagitis causing mucosal injury may be a mechanism of increased antigen exposure.

Development of a megaesophagus with a sigmoid-shaped distal part in patients with achalasia--even in the course of successful myotomy with reduction of the resting pressure of the lower esophageal sphincter--is often the expression of an irreversible progression of the disease. Management of patients with end-stage achalasia and aperistaltic, dilated "burned-out" esophagus--with or without peptic stenosis--is a therapeutic challenge for gastroenterologists and surgeons. We report on a 37-year-old female patient with decompensated dolichomegaesophagus following multiple endoscopic and operative interventions at the lower and upper esophageal sphincters presenting with severe dysphagia and weight loss. Esophageal resection with gastric tube pull-up was indicated and performed as a two-stage procedure with ischaemic preconditioning of the esophageal substitute, with the intention of a microcirculatory improvement of the gastric fundus for the anastomosis, which was thought to be potentially compromised due to the previous interventions. The postoperative course was uneventful with dysphagia completely relieved and quality of life markedly improved. The concept of ischaemic preconditioning of the gastric tube offers, in particular, patients with esophageal resection for benign motility disorders, such as end-stage achalasia after multiple surgical procedures at the cardia and gastric fundus, a safe and practicable alternative to one-stage esophageal resection and reconstruction.

Für die Ätiologie des Schatzki Rings werden refluxbedingte, angeborene, sowie sekundär morphologische Veränderungen (Verkürzung des Ösophagus bei Hiatushernie) diskutiert. In neuester Zeit wurde bei Kindern das gehäufte Vorkommen des Schatzki Rings bei der eosinophilen Ösophagitis beschrieben. Die folgende Untersuchung geht der Frage nach, ob eine derartige Assoziation auch beim Erwachsenen existiert.

Fallbericht: Ein 40-jähriger Patient klagt über rezidivierende krampfartige Oberbauchschmerzen, die teilweise mit Diarrhoe, selten mit Übelkeit und Erbrechen verbunden sind. Im Vorjahr waren zwei Episoden mit ähnlicher Symptomatik aufgetreten. Damals war in einer MRT-Abdomen Untersuchung die Diagnose eines M. Crohn des Dünndarms gestellt worden. Eine Ileokoloskopie und Ösophagosgastroduodenoskopie (ÖGD) hatten weder makroskopisch noch mikroskopisch einen pathologischen Befund gezeigt. Unter einer Steroidtherapie war es jeweils zum vollständigen Sistieren der Beschwerden gekommen. Nach Ausschleichen der Steroide war der Patient etwa 2 Monate beschwerdefrei. Vor 10 Jahren war er schon einmal wegen abdomineller Beschwerden und Ascites mit einer hohen Eosinophilenzahl in der Aciteszytologie in Behandlung gewesen.

BACKGROUND:Patients with achalasia require repeated invasive therapies and may experience multiple complications. The objectives of this study were to determine the incidence of such complications, causes of death, and life expectancy in 253 patients. METHODS:Patients consisted of two groups: group A comprised 177 patients with newly diagnosed achalasia; group B consisted of 76 patients in whom the diagnosis had been established in external institutions. All patients regularly underwent structured interviews and were reinvestigated if changes in health status occurred. Survival rates were determined by Kaplan-Meier estimates and were compared with those of an average German population. Causes of death were determined from hospital records, information supplied by private physicians, and from death certificates. RESULTS:Complete follow-up was obtained in 98.9% (group A) and in 100% (group B) of all patients. The observation period for group A ranged from 2 to 33 years and for group B from 2 to 26 years (disease duration: 4-68 years). The most frequent complications were reflux esophagitis (group A: 6.2%, group B: 19.7%) and megaesophagus (group A: 6.2%, group B: 21.0%). Thirty-six patients had died during follow-up. Five of these deaths were related to achalasia. In group A, the estimated 20-year survival rates in patients with achalasia [76% (95% confidence interval (CI): 66-85%)] did not significantly differ from those in controls 80% (95% CI: 71-89%). In group B, 25-year survival rates were also similar in patients [87% (95% CI: 78-97%)] and controls [86% (95% CI: 76-97%)]. CONCLUSION:Patients with achalasia experience a significant number of complications. Causes of death and life expectancy, however, do not differ from those of the average population.

Einleitung: Bei einem 69-jährigen Patienten besteht seit Anfang 2006 eine zunehmende Belastungsdyspnoe und ein lagerungsabhängiges, epigastrisches Druckgefühl.