ACHALASIA

Dr. Yusmaidi, SpB - KBD

Digestive Surgery, lampung Medical School

Lampung
 Definition
 Achalasiais a primary esophageal motility disorder
characterized by the absence of esophageal peristalsis
and impaired relaxation of the lower esophageal
sphincter (LES) in response to swallowing.
 The LES is hypertensive in about 50% of patients.
 Theseabnormalities cause a functional obstruction at
the gastroesophageal junction (GEJ).
 Signs and symptoms
Symptoms of achalasia include the following:
•Dysphagia (most common)
•Regurgitation with rumification
•Chest pain
•Heartburn
•Weight loss
Physical examination is noncontributory.
 Diagnosis
Laboratory studies are noncontributory.
Studies that may be helpful include the following:
 Barium swallow: Bird’s beak appearance, esophageal dilatation
 Esophageal manometry (the criterion standard): Incomplete LES
relaxation in response to swallowing, high resting LES pressure,
absent esophageal peristalsis
 Prolonged esophageal pH monitoring to rule out gastroesophageal
reflux disease and determine if abnormal reflux is being caused
by treatment
 Esophagogastroduodenoscopy to rule out cancer of the GEJ or
fundus
 Concomitant endoscopic ultrasonography if a tumor is suspected
Barium swallow
demonstrating the bird-
beak appearance of the
lower esophagus, dilatation
of the esophagus, and stasis
of barium in the esophagus
Esophageal manometry (see the
image) is the criterion standard in
helping to diagnose the classic
findings of achalasia

•Incomplete relaxation of the

LES in response to swallowing
•High resting LES pressure
•Absent esophageal peristalsis
 Treatment
Palliation of dysphagia is the key  relieve
functional obstruction of distal esophagus
Pharmacotherapy
Botulinum toxin
Esophageal dilation
Operative myotomy
Algorythm
 Guideline The American College of
Gastroenterology
Treatment recommendations are as follows:
 Initial therapy should be either graded pneumatic dilation (PD) or
laparoscopic surgical myotomy with a partial fundoplication in patients
fit to undergo surgery
 Procedures should be performed in high-volume centers of excellence
 Initial therapy choice should be based on patient age, sex, preference,
and local institutional expertise
 Botulinum toxin therapy is recommended for patients not suited to PD
or surgery
 Pharmacologic therapy can be used for patients not undergoing PD or
myotomy and who have failed botulinum toxin therapy (nitrates and
calcium channel blockers most common)
Pharmacotherapy

Poorly absorbed and short lived, best

reserved as adjunct to other therapies
Nitrates
Ca++ channel blockers
Anticholinergics
Opiods
Botulinum toxin therapy
 Botox injection
 Bind to cholinergic nerves and irreversibly
inhibit Acetyl Choline release
 60 - 85% of patient get relief but 50% get
recurrent symptoms within 6 months.
 Endoscopically injected
 For patients who are not candidates for other
therapies
 Botox injection
 Advantages: safety, ease of administration,
minimal side effects
 Disadvantages: expensive, need for multiple
injections, and efficacy decreased with repeated
injection
 Cause obliteration of the dissection planes
between submucosa and muscular layer which
will make subsequent surgery more difficult and
increase risk of perforation.
Pneumatic dilator
Esophageal dilation (under fluroscopy)
 -Standard nonoperative therapy
 -Break the muscle fibers
 -For pts with limited life expectancy
 -Can have repeated dilatation
 -60-80% success rate, 5yr recurrence rate 50%
 -Efficacy is decreased after second dilatation
 -Perforation rate ~ 2%
 -PPI reduces the need for repeat dilatation
Dilatation vs Botox
 Surgical treatment
 Excellent results in 90-95%
 1914 - Ernest Heller- double myotomy
 Modified by Zaaijer- single myotomy
 World’s largest experience
Brazil, Chagas’ disease-endemic
1 in 8 inhabitants, in which 5% develops achalasia
 Traditionally trans-thoracic or trans-abdominal
 Now minimally invasive Laparoscopic / Thoracoscopic
 Robotic Heller myotomy
 Indication
 Younger than 40yrs old (group which PD is <50% effective)
 High risk of perforation
- Esophageal diverticula
- Previous surgery of GE junction
- Tortuous or dilated distal esophagus
 Recurrent symptoms despite Botox or PD therapy
 Personal choice of therapy
- Lower risk of perforation
- Better long term outcome
- Decrease chance of re-intervention
Esophageal myotomy
Heller myotomy
extending 1.5 cm onto
the gastric wall.
Dor fundoplication, left
row of sutures (after
division of short gastric
vessels).
Completed Dor fundoplication
 Surgical complication

Intra-op: Mucosa perforation

Post-op:
- Dysphagia- adhesion, inadequate myotomy
- GERD- long myotomy, nerve damage
- Delay perforation- inadequate myotomy
Controversies ?

 Which esophageal technique should be

used?
 Any role for anti-reflux procedure?
Trans-thorasic

-Excellent result
-Less GERD* compare to trans-abdominal
* Phreno-esophageal ligament is not disrupted and shorter myotomy
- No fundoplication is necessary
Trans-abdominal

Excellent result – comparable to trans-thoracic

More GERD*, less dysphagia
*Longer myotomy onto stomach (3cm)
Laparocopic

Excellent result
*Decrease hospital stay (average 42-48hrs post-op)
Improve GERD by antireflux procedure
Comparison
 Currently, no prospective randomized trials
comparing the various approaches to myotomy
 Excellent results
 Technique used should depend on individual
surgeon’s comfort and experience
 Anti-reflux should be performed with abdominal
approach
Dilation vs Surgery
 POEM (Per Oral Endoscopic Myotomy)
 POEM has been introduced relatively recently as a novel
approach to achalasia.
 This procedure is performed under general anesthesia with
endotracheal intubation.
 A 2-cm longitudinal mucosal incision is made on the mucosal
surface to create a mucosal entry to the submucosal space.
 An anterior submucosal tunnel is created downwards, passing
the gastroesophageal junction and about 3 cm into the proximal
stomach
 POEM
 In a comparative study that evaluated the
symptomatic and objective outcomes of of
laparoscopic Heller myotomy with POEM for
achalasia, Bhayani et al reported a shorter
hospitalization in those who underwent POEM than
those who underwent myotomy, but both procedures
showed equivalent improvement in symptoms and
esophageal physiology as well as equivalent
postoperative esophageal acid exposure. Worrell et
al reported similar findings.
POEM

Gastroesophageal reflux is reported in up to 50%

of patients after POEM, replicating the results
obtained when a myotomy alone was performed
without an antireflux operation.
 Surgical revision in patients with recurrent
dysphagia after POEM might be challenging. The
presence of adhesions between the submucosal
and longitudinal muscular layers after POEM might
make the dissection at this level very difficult.
 Conclusion
 Ballon dilation is the first choice
 Laparoscopic Heller myotomy, preferably with anterior (Dor;
more common) or posterior (Toupet) partial fundoplication
 Per Oral Endoscopic Myotomy (POEM)
Patients in whom surgery fails may be treated with an
endoscopic dilatation first. If this fails, a second operation
can be attempted once the cause of failure has been
identified with imaging studies. Esophagectomy is the last
resort
THANK YOU