Achalasia of the esophagus

Question 1

Manometric findings of hypertensive LES resting pressure, nonrelaxing LES, and aperistalsis of esophageal body, and an elevated lower esophageal baseline pressure.

Answer 1

Achalasia

Question 2

Findings on barium swallow for achalasia

Answer 2

“Birds beak” (created by a nonrelaxing LES).

Question 3

What do fluoroscopic videoimages reveal in patients with achalasia?

Answer 3

A flaccid, nonperistaltic esophagus (devoid “stripping waves”)

Question 4

What is the proposed etiology of achalasia?

Answer 4

Absence of inhibitory ganglion cells in myenteric (Auerbach) plexus.

Question 5

Clinical symptoms of achalasia

Answer 5

Progressive dysphagia to solids and liquids, regurgitation of food, chest pain and weight loss.

Question 6

What are the outcomes of oral nitrates and calcium channel blockers in the treatment of achalasia?

Answer 6

Sporadic efficacy and only short term success.

Question 7

Does botox injection or pneumatic dilatation have better short term success in patients with achalasia?

Answer 7

Dilatation.

Question 8

What is the standard surgical management in patients with achalasia?

Answer 8

Heller myotomy (esophageal myotomy often accompanied by a partial fundoplication [Dor or Toupet])

Question 9

Why is partial fundoplication used in preference to a complete 360 degree fundoplication in the surgical treatment of achalasia?

Answer 9

To avoid esophageal dysfunction secondary to outflow obstruction.

Question 10

Why is fundoplication included in the surgical treatment of achalasia?

Answer 10

Because of increased incidence of gastroesophageal reflux secondary to decreased outflow resistance.

Question 11

What percentage of patients have either complete relief of dysphagia or only mild persistent dysphagia after Heller myotomy for achalasia?

Answer 11

90% (at 5 years)

Question 12

Which patient is more likely to have relief of dysphagia postoperatively: patient with preop LES resting pressure of 40, or with preop LES resting pressure of 20?

Answer 12

Patients with higher preop LES resting pressures are 21 x more likely to have relief of dysphagia after surgical myotomy. So patient with LES pressure of 40 is more likely to have long term relief of dysphagia after surgery.

Question 13

If the following patients had the same preop LES pressure, which will have greater improvement in postoperative dysphagia - patient in whom the LES pressure was reduced to 20mmHg or reduced to 10mmHg after surgery?

Answer 13

Patients with a greater decrease in LES pressure after surgery have greater improvement in dysphagia.

Question 14

Does preoperative endoscopic intervention affect the success of subsequent surgical myotomy?

Answer 14

Yes. Persistent or recurrent symptoms nearly twice that in patients who underwent prior intervention (botox/dilatation)

Question 15

What is the most common failure during surgical esophageal myotomy leading to persistent symptoms?

Answer 15

Failure to attain adequate distal extension of the myotomy (over fundus of stomach).

Question 16

Describe a myotomy for achalasia.

Answer 16

After mobilizing the esophagus and exposing GE junction, the esophageal longitudinal and circular muscles are divided down to the mucosa (beginning with the upper limit of the anterior extension of the esophageal hiatus and onto the anterior wall of the fundus of the stomach for 2 to 3 cm). Total length of myotomy is 4-6cm. Edges of myotomy should be separated from underlying mucosa for 40-50% of the esophageal circumference.

Question 17

What percentage of patients will have some recurrence of mild symptoms of dysphagia, regurgitation, heartburn or chest pain after lap myotomy and partial fundoplication?

Answer 17

40-50%

Question 18

What is an effective treatment for recurrent dysphagia following surgical myotomy, that do not respond to lifestyle modifications?

Answer 18

Pneumatic dilatation.

Question 19

Treatment for megaesophagus (end stage achalasia)

Answer 19

Esophagectomy