Achalasia management: the South American viewpoint

Achalasia is usually quoted as a rare primary esophageal disorder with an unknown etiology.^[1] This rarity leads to frequent misdiagnosis as shown by high rate of patients with achalasia referred for antireflux surgery.^[2] The two affirmatives that achalasia is rare and lacks an etiology; however, may not be true in South America. In this continent, a local disease - Chagas disease or American trypanosomiasis - caused by the inoculation of a parasite through a bug bite leads to an esophagopathy almost indistinguishable from idiopathic achalasia found in other continents, as shown in the paper by Dr. Dantas in this seminar.

Chagas disease currently affects 5-18 million people and an estimated 15-20% will develop Chagasic esophagopathy.^[3] More than this, autochthonous cases of Chagas disease have been reported up to Southern United States^[4] and an uncountable number of immigrants carry the disease worldwide.^[5] This high incidence of the disease in endemic areas brought a large experience in the management of these patients by South American gastroenterologists and surgeons. Unfortunately, most of this experience is published in local languages making it grey literature for international readers.

Despite several similarities, Chagas disease esophagopathy is characterized by massive dilatation of the esophagus a finding rare in idiopathic achalasia.^[6] The treatment for non-advanced achalasia is well established and based on cardiomyotomy (surgical or recently endoscopic) or forceful dilatation of the cardia.^[7] The therapy for end-stage disease is; however, controversial and the familiarity of these conditions by South American physicians may be useful. Some unconventional or long-forgotten surgical procedures are still in use in Brazil and some surgeons acquired a large experience with these techniques. Esophageal resection is also a popular choice for dilated megaesophagi.

This seminar reflects the lessons learned by different Brazilian centers highly experienced in the treatment of Chagas disease esophagopathy. Different treatment options are discussed in the light of personal experiences emphasizing aspects not frequently adopted by North American and European surgeons.^[8]