Anesthetic management of a patient with achalasia, a disease with a considerable risk for aspiration under anesthesia

Abstract

Background: Achalasia is a rare condition characterized by dysfunction of esophageal motility and impaired relaxation of the lower esophageal sphincter. Anesthetic management of these patients is challenging due to the elevated risk of regurgitation and aspiration.

Case presentation: A 53-year-old man diagnosed with achalasia was scheduled for renal cancer surgery before esophageal myotomy. Since his severe dysphagia suggested the possibility of vomiting and aspiration under anesthesia, a stomach tube was inserted before induction of general anesthesia. After preoxygenation, rapid sequence induction was performed and an antiemetic was administered to prevent postoperative vomiting. Although anesthetic management was uneventful, the inserted stomach tube coiled up in the dilated esophagus and substantial residue was aspirated via the tube even after a prolonged fasting period.

Conclusion: Anesthesiologists should be familiar with achalasia even though it is an uncommon disease, since affected patients are at risk of regurgitation and aspiration under anesthesia.

Keywords: Achalasia; Aspiration; Rapid sequence induction; Regurgitation.

Fig. 1

Chest X-ray demonstrated enlargement of the mediastinum (white arrows) and presence of air-fluid levels in the thoracic esophagus (yellow arrowhead)

Fig. 2

A Axial computed tomography (CT) image showing the enlarged esophagus filled with residue (arrow). B Coronal CT image showing dilation of the upper part and narrowing of the lower part of the esophagus, presenting a bird beak shape (white arrow). The left renal tumor is also seen (yellow arrowhead)

Fig. 3

Chest X-ray image demonstrating enlargement of the mediastinum (white arrows). The stomach tube had formed a loop in the dilated esophagus (yellow arrowheads)