Surgical management of achalasia in Zaria, Northern Nigeria

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.

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.

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.

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.