SJLA_2024_A9: Surgical Management of Achalasia

Abstract

Introduction: Achalasia is a rare neurological disorder, in which the esophagus fails to relax. The esophagus also has a marked absence of peristalsis. In <50% of patients, the lower esophageal sphincter is hypertensive. This condition causes a functional obstruction at the gastroesophageal junction. Background: Treatment is to ease the symptoms of achalasia by decreasing the outflow resistance caused by a nonrelaxing and hypertensive lower esophageal sphincter. Surgical options are laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy. The recommended step for reducing pressure across the lower esophageal sphincter is surgical myotomy, which can be done laparoscopically. This procedure will cut the circular muscle fibers running across the lower esophageal sphincter, leading to relaxation. LHM can potentially cause uncontrolled gastroesophageal reflux, so it typically pairs with an antireflux procedure such as Nissen, the posterior (Toupet), or the anterior (Dor) partial fundoplication. The anterior fundoplication is the more common choice. LHM with partial fundoplication is the surgical procedure of choice. The important thing is that the fundoplication is partial, not complete, so as not to cause postoperative dysphagia, which is more severe with Nissen fundoplication. The clinical success rate of LHM is high (76%–100%) at 35 months, with a low mortality rate of 0.1%. Disease progression after 5 years subsequently reduces the success rate. Methods: Video demonstration of case of achalasia treated with Heller myotomy. Results: Video demonstration of case of achalasia treated with Heller myotomy. Discussion: Video demonstration of case of achalasia treated with Heller myotomy. Conclusion: Video demonstration of case of achalasia treated with Heller myotomy.