Achalasia 

Author: Robert B. Yates, MD; Edward Verrier, MD
Institution: University of  Washington
Date Reviewed: October 2014
Learning Domain: General Thoracic
Learning Objective: Benign Esophageal Disease
PowerPoint File: Achalasia

 

Diagnosis of Achalasia

  • Clinical history
    • Dysphagia, regurgitation, weight loss
  • Manometry
    • Types I/II/III, non-relaxing LES
  • Esophagram
    • Dilated esophagus with distal tapering
  • Endoscopy
    • ‘Tight LES’ and dilated esophagus; retained food

 

Options in Management of Achalasia

  • Pneumatic Dilation
    • Good for high operative risk patients; generally require multiple dilations
  • Botox injection
    • Temporary symptomatic improvement
  • Esophagomyotomy +/- Fundoplication
    • Extended myotomy and Toupet
  • Esophagectomy
    • Almost never for initial treatment
    • Rarely needed even for recurrent dysphagia

 

Non-Operative Management

  • Medications
    • Calcium channel blockers
    • Nitrates
  • Botulinum toxin
    • May offer temporary relief of dysphagia
    • Can cause periesophageal inflammation
  • Pneumatic dilation
    • As effective as myotomy, but requires multiple dilations and associated with esophageal perforation

 

Esophagectomy for Achalasia

  • Never indicated as initial treatment of achalasia
  • Infrequently required after failed myotomy
  • Should perform re-operative myotomy or balloon dilation prior to proceeding with esophagectomy

 

Learning Points

  • Diagnosis of Achalasia
    • Clinical history, manometry, UGI, EGD
  • Management of Achalasia
    • Laparoscopic extended esophagogastric myotomy
    • Partial fundoplication reduces postoperative GERD
    • Pneumatic dilation acceptable in prohibitively high-risk operative patients
    • Botox only offers temporary relief of symptoms and can increase difficulty of operative myotomy