Achalasia

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Achalasia
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Achalasia

• Most common primary disorder of the esophagus
• Characterized by insufficient peristalsis and
  incomplete relaxation of LES
• Secondary to neuronal degeneration of the
  myenteric plexus b/w the esophageal musc.
• Loss of inhibitory neurons of the LES

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Causes

• Viral
• Pseudoachalasia
• Tight Nissen
• Angelchik prosthesis
• Tumor
• Chagas Disease

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Diagnosis

• Radiographic
• Birds beak
• Megaesophagus

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Diagnosis

• Manometry
• Aperistalsis
• Hypertensive LES
• Positive Intraesophageal pressure
• Failure of LES to relax with swallowing

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Myotomy

• Abdominal Approach
• Principles
• Adequate myotomy
• Divide Circular and Longitudinal muscle
• 6-8 cm proximal to GE junction
• 2-3 cm on stomach
• Toupet anti-reflux valve

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Laparoscopic Technique

• Port Placement
• Five Ports
• Supraumbilical
• Liver retraction
• Two operating ports (5mm and 10mm)
• first assistant

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X
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Esophageal Exposure

• Incise the Gastrohepatic Ligament
• Expose the right crus
• Incise the phrenoesophageal ligament
• Identify the esophagus and the left vagus nerve

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Esophageal Myotomy

• Incise the adventitia overlying the esophagus
• Split longitudinal muscle and identify deeper
  circular muscle
• Incise circular muscle cephalad for 6-8 cm
• Caudal myotomy onto GEJ and stomach for _at_ least 2
  cm

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Longitudinal Muscle
Circular Muscle
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Completed Myotomy
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Vagus Nerve
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Myotomy

• Myotomy should expose 180 degrees of pouting
  submucosa
• Dissection is more difficult distally secondary
  to muscular sling surrounding GEJ
• Jump over Anterior vagus
• Endoscopy to rule out perf, ensure complete
  myotomy

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Fundoplication

• Toupet posterior 180 fundoplication
• Dor anterior 180 fundoplication
• Does not disrupt hiatal mechanism
• Relatively simple
• Utilized for patching esophageal perforations

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Toupet
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Dor Fundoplication