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Ann Thorac Surg 1998;66:939-941
© 1998 The Society of Thoracic Surgeons

Case Reports

Tracheal obstruction in achalasia: a role for airway stenting?

Richard G. Berrisford, FRCS(CTh)a, Aung Oo, FRCSa, Martin J. Walshaw, FRCPa, Michael J. Drakeley, FRCSa

a The Cardiothoracic Centre, Liverpool, England, United Kingdom

Accepted for publication March 24, 1998.

Address reprint requests to Mr Berrisford, Royal Devon and Exeter Hospital, Barrack Rd, Exeter, Devon, EX2 5DW, England
e-mail: (richard{at}berrisford.u-net.com)


   Abstract
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 Abstract
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 Comment
 References
 
We describe an 82-year-old woman who presented with acute tracheal obstruction secondary to advanced, asymptomatic achalasia. Conventional treatment of her achalasia failed to relieve recurrent episodes of airway obstruction requiring endotracheal intubation. Because she was not fit for an operation, a Gianturco endotracheal stent was placed bronchoscopically. She remains without respiratory or upper gastrointestinal symptoms 2 years later. Recent information regarding the pathophysiology and surgical treatment of this complication is reviewed.


   Introduction
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 Abstract
 Introduction
Comment
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Acute airway obstruction is a rare life-threatening complication of achalasia that has seldom been reported by thoracic surgeons. The purpose of this case report is to bring the complication to the attention of thoracic surgeons, to review recent theory as to its pathophysiology, and to describe a means of palliation by tracheal stenting.

An 82-year-old woman was admitted to her local hospital with acute onset of breathlessness at night. She had suffered no previous respiratory symptoms or dysphagia. Five days before admission she had eaten a full Christmas dinner.

On examination she was cyanosed and her breathing was stridulous. Within 2 hours of admission she required endotracheal intubation and ventilation. An air-filled shadow was present on her chest radiograph, which was consistent with a megaesophagus. Further attempts at extubation were unsuccessful.

She was transferred to the nearest cardiothoracic unit. A nasogastric tube was passed to decompress her esophagus. The patient was thought to have laryngeal edema secondary to aspiration and was treated with a 5-day course of intravenous steroids. A concomitant chest infection was treated with antibiotics. Her condition improved, but after initial successful extubation she required reintubation within 5 days for respiratory obstruction.

At bronchoscopy the posterior tracheal wall was seen bulging anteriorly, completely obstructing the airway from 2 cm below the cords to the carina. The cause of her airway obstruction was clearly identified as achalasia. A contrast swallow demonstrated the megaesophagus with appearances at the esophagogastric junction typical of achalasia. Some contrast was seen to pass into the stomach.

Intravenous nitrates, calcium antagonists, and sequential balloon dilation of the lower esophageal sphincter allowed successful extubation, but she continued to suffer repeated episodes of stridor.

Because she was not fit for myotomy or esophageal resection, we elected to palliate her airway symptoms by tracheal stenting (Fig 1). A 30 mm x 50 mm double Gianturco stent was placed under bronchoscopic vision. Three days later a percutaneous endoscopic gastrostomy tube was passed to assist hyperalimentation. She was transferred to a nursing home a week later. She has had no further episodes of airway obstruction and is managing to eat normally 2 years later.



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  		Fig 1. Chest radiograph showing megaesophagus with tracheal stent in situ.

 

   Comment
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The majority of publications reporting this uncommon complication have been in the gastroenterology or otolaryngology literature. There have been very few reports in the thoracic surgical literature [1–3]. Most articles describe life-threatening upper airway obstruction relieved by a variety of treatments including tube decompression [4], balloon dilation [5], Heller myotomy [1, 6], and, more recently, cricopharyngeal myotomy [7, 8].

Here we report tracheal stenting as a treatment for this complication. We have described this as "palliative" because Gianturco airway stents are not currently recommended for treatment of benign conditions. Esophagectomy would have been indicated in a fit patient regardless of age, both to relieve airway obstruction and to reduce the future risk of aspiration from a megaesophagus. The patient we describe had significant respiratory comorbidity precluding even transhiatal resection. Other, more conservative treatment options were unsuccessful in our patient, who was not fit for an operation. It is interesting that our patient was previously asymptomatic, a common finding in reports to date [8].

The literature was last reviewed by Becker and Castell [6], who proposed a deficient belch mechanism as the underlying abnormality. Subsequently Massey and associates [9] demonstrated an abnormal upper esophageal sphincter belch reflex in many patients with achalasia compared with normal controls. Cricopharyngeal myotomy has relieved respiratory symptoms in 2 reported patients [7, 8], in 1 of whom a Heller myotomy had failed to relieve the respiratory symptoms [7]. Cricopharyngeal myotomy appears to be a logical surgical treatment. Tracheal stenting is an alternative palliative treatment in the patient who is unfit for an operation.


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  1. Morrow A., Coady T.J., Seaton D. Tracheal compression relieved by cardiomyotomy. Thorax 1982;37:776-777.[Free Full Text]
  2. Chijimatsu Y., Hasumi K., Inatomi K., Tamura M., Homma H. Airway obstruction in achalasia. Chest 1980;78:348-350.[Abstract/Free Full Text]
  3. McLean R.D., Stewart C.J., Whyte D.G. Acute thoracic inlet obstruction in achalasia of the oesophagus. Thorax 1976;31:456-459.[Abstract/Free Full Text]
  4. Wickramasinghe L.S., Chowdhury C.R., Pillai S.S., Ghosh S. Distended oesophagus as a cause of bilateral recurrent laryngeal nerve palsy. Postgrad Med J 1988;64:958-959.[Abstract/Free Full Text]
  5. Kendall A.P., Lin E. Respiratory failure as presentation of achalasia of the oesophagus. Anaesthesia 1991;46:1039-1040.[Medline]
  6. Becker D.J., Castell D.O. Acute airway obstruction in achalasia. Possible role of defective belch reflex. Gastroenterology 1989;97:1323-1326.[Medline]
  7. Ali G.N., Hunt D.R., Jorgensen J.O., deCarle D.J., Cook I.J. Esophageal achalasia and coexistent upper esophageal sphincter relaxation disorder presenting with airway obstruction. Gastroenterology 1995;109:1328-1332.[Medline]
  8. Campbell K.L., Logie J.R., Munro A. Cricopharyngeus myotomy for upper airway obstruction in achalasia. Br J Surg 1995;82:1668-1669.[Medline]
  9. Massey B.T., Hogan W.J., Dodds W.J., Dantas R.O. Alteration of the upper esophageal sphincter belch reflex in patients with achalasia. Gastroenterology 1992;103:1574-1579.[Medline]



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[Abstract] [Full Text] [PDF]

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