What is the incidence of pulmonary complications in patients with achalasia ?
A.C. Duranceau, C. Deschamps, E. Lafontaine (Montreal)
Documented pulmonary complications are reported mainly for achalasia. Nocturnal aspiration is reported to cause recurrent aspiration pneumonitis in 10 p. cent of all untreated patients . Ellis , reporting on 269 patients treated for achalasia found evidence of aspiration pneumonia in 26 of them, one with a lung abscess. Later, Rees el al.  described a history of single or repeated episodes of aspiration pneumonia in 14 of their 84 patients with achalasia. Effler reported pulmonary complications secondary to nocturnal aspirations of esophageal contents in 24 p. cent of his 100 patients, 8 of them actually showing roentgenographic evidence of pulmonary damage. Black et al.  found pulmonary symptoms in 50 of their 108 patients (46.3 %). In most, this consisted of mildly productive coughing which may not have been related to the esophageal condition. 8 patients (7.4 %) had choking attacks while 13 (12%) showed unequivocal evidence of aspiration pneumonitis. Olsen  described the acute and chronic form of pulmonary damage that affected 10 p. cent of the 601 patients in their series. Five of their patients had the more chronic form of pulmonary infection caused by atypical mycobacterias.
Mycobacterium fortuitum, a non tuberculous rapidly growing acid fast bacteria, resistant to most antibiotics, may produce pulmonary infection by developing in a fatty fluid supernatant retained in the esophagus. Oil, which is cleared more slowly than other substances, by the tracheobronchial tree, impairs phagocytosis, thus favoring the development of these atypical mycobacterial infections [3, 9].
Among the acute situations which may occur secondary to achalasia, airway obstruction has been reported to require immediate intubation and myotomy . Massive pulmonary aspiration remains one of the most catastrophic event that may occur during initiation of surgical treatment for achalasia patients. Allen and Clagett[l] reported that one of two deaths in their series resulted from aspiration during induction of anesthesia, obviously due to an incomplete preoperative esophageal toilet. Each patient must be carefully evaluated for the presence of retained food and liquid in the esophagus [11, 7]. It is essential that the dilated esophagus be carefully emptied of food and secretions before the operation, in order to minimize the risks of aspiration during anesthesia induction and after. A liquid diet is given during the day before surgery and a nasogastric tube is passed into the dilated esophagus the night before the operation to provide through emptying of the esophagus. The procedure is repeated on the morning of the operation to remove swallowed nocturnal secretions. All preoperative medication should be administered parenterally for reliable effectiveness.