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Controversies in Management of Achalasia

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Esophageal achalasia is a primary motility disorder of unknown etiology. It is characterized by lack of esophageal peristalsis and failure of the lower esophageal sphincter to relax appropriately in response to swallowing. The goal of treatment is to improve esophageal emptying and patient’s symptoms by decreasing the functional obstruction at the level of the gastroesophageal junction. This can be accomplished by either endoscopic modalities (intra-sphincteric injection of botulinum toxin, pneumatic dilatation, per oral endoscopic myotomy) or by a laparoscopic Heller myotomy.

Results

Review of the current literature suggests that a laparoscopic Heller myotomy should be considered today the primary form of treatment for achalasia and recommends a treatment algorithm for this disease.

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Conflict of interest

The authors have no conflicts of interest to declare.

Author information

Authors and Affiliations

  1. Department of Surgery, Center for Esophageal Diseases, Pritzker School of Medicine, University of Chicago, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL, 60637, USA

    Marco G. Patti

  2. Department of Surgery, Boston VAMC, Harvard Medical School, Boston, MA, USA

    Piero M. Fisichella

Authors
  1. Marco G. Patti
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  2. Piero M. Fisichella
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Corresponding author

Correspondence to Marco G. Patti.

Additional information

Answers:

1. c

2. d

3. b

4. b

5. b

6. a

7. b

8. d

Questions

Questions

Question 1

Intra-sphincteric injection of Botulinum toxin:

a. Is as effective as pneumatic dilatation and Heller myotomy

b. Can be repeated multiple times with great efficacy

c. Can cause fibrosis at the level of the gastroesophageal junction

d. Should be considered the first line of treatment for every patient

Question 2

Pneumatic dilatation

a. Should be considered the first line of treatment for every patient

b. It is associated with <1 % perforation rate

c. Is as effective in the long-term as a Heller myotomy

d. Is very effective in patients who have recurrent dysphagia after Heller myotomy

Question 3

Per Oral Endoscopic Myotomy

a. Does not require advanced endoscopic skills

b. Gives good short term results

c. Should be considered the standard of care for achalasia

d. Is not associated to postoperative gastroesophageal reflux

Question 4

A left thoracoscopic myotomy

a. Is today the standard operation for patients with achalasia

b. Is associated to a very high rate of postoperative gastroesophageal reflux

c. Can be performed as an outpatient procedure

d. Extends for 2.5 cm onto the gastric wall

Question 5

A laparoscopic Heller myotomy

a. Should be extended for 5 mm onto the gastric wall

b. Should be extended for 2.0-2.5 cm onto the gastric wall

c. Should be extended for 1 cm onto the gastric wall

d. Should stop at the squamo-columnar junction

Question 6

After a laparoscopic Heller myotomy (without fundoplication)

a. A very high percentage of patients have gastroesophageal reflux

b. No fundoplication is necessary

c. Rarely causes postoperative gastroesophageal reflux

d. Esophagitis is rarely present

Questions 7

What type of fundoplication should be performed after a Heller myotomy?

a. A Collis Nissen fundoplication

b. A partial fundoplication (Dor or Toupet)

c. A Nissen fundoplication

d. A Hill fundoplication

Question 8

The best results for patients with achalasia are obtained when there is:

a. A skilled gastroenterologist

b. A skilled radiologist

c. A skilled surgeon

d. A Multidisciplinary team with expert radiologists, gastroenterologists and surgeons

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Patti, M.G., Fisichella, P.M. Controversies in Management of Achalasia. J Gastrointest Surg 18, 1705–1709 (2014). https://doi.org/10.1007/s11605-014-2556-7

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  • DOI: https://doi.org/10.1007/s11605-014-2556-7

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