Traitement de l’achalasie de l’œsophage
Treatment of oesophageal achalasia
Idiopathic achalasia is an affliction with well defined radiological and manometric clinical criteria, although atypical or intermediary forms with diffuse oesophageal spasm have been described. The etiology is unknown but progress has been made regarding the understanding of the physiopathological mechanisms — involvement of the NO mediated inhibitory pathway — and physiopathology. Ganglionitis with lymphocytic infiltration is perhaps related to a herpes group virus. The observation of a serum factor altering the functioning of human myenteric neurons by the Nantes team raises the possibility of an etiological treatment aimed at dysimmune mechanisms. Until an etiological target is found, treatment consists of removing the distal functional obstacle. Myorelaxants, and particularly nifedipine, should be proposed in the early forms and in elderly subjects. Botulinum toxin is disappointing in retrospect. It is useful in vigorous achalasia, in elderly subjects. Pneumatic dilation and coelioscopic Heller myotomy are treatments that aim at a definitive result. The endoscopic as well as surgical procedural variants render comparisons difficult. A European study comparing progressive pneumatic dilation to coelioscopic myotomy with Dorr valve is underway. The long term results of these two therapies are less than expected and justify regular monitoring of patients for treatment of stasis oesophagitis, reflux, endobrachyoesophagus and the risk of carcinoma.
E.H. METMAN, L. NEGREANU, Sonia DEBBABI
botulinum toxin, Heller myotomy, idiopathic achalasia, pneumatic dilation