Esophagus—Achalasia
Concept
Esophageal aperistalsis (loss of Auerbach’s plexus), failure of the lower esophageal sphincter to relax, and resultant esophageal dilation
Way Question May be Asked?
“37 y/o female presents on referral from her GI doctor with difficulty swallowing liquids and solids and subster- nal pain after meals for approximately 1 year.” Rarely will you be given the diagnosis on referral or shown the typical
“bird’s beak” on UGI. Patients may also have aspiration or referral for a megaesophagus.
How to Answer?
Must be methodical in your approach to dysphagia because the scenario will end up being something you leave out. DDx includes spasm, achalasia, stric- ture, tumor-benign and malignant.
First, complete history including risk factors for malig- nancy as well as for the onset of the dysphagia.
Second, complete physical exam including epigastric masses and lymph node basins (will all be negative but if you leave out the PE, the pt will end up having a pronounced supraclavicular node and the scenario will have changed to esophageal cancer with obvious mets).
Appropriate preoperative studies including full labs, EKG, CXR.
Appropriate work-up of dysphagia which always includes UGI, EGD (risk of malignancy increased in these pts), and manometry
Treatment should also be stepwise with:
(1) Attempts at medical therapy with nitrates and calcium channel blockers
(2) Esophageal dilatation with pneumatic balloon under fluoroscopy to dilate and disrupt the fibers of the LES (be prepared for scenario to change to perforation here~4% risk). Dilatation alone approx. 70% response rate.
(3) BoTox injection with 80 units in four divided doses directed into the LES by endoscopy—
consider in older, debilitated pts
(4) Surgical myotomy, can be done laparoscopically or transthoracic. (only describe if you are familiar with minimally invasive techniques otherwise, transthoracic approach.)
Procedure
Left lateral transthoracic approach Double lumen ETT
Esophageal bougie
Longitudinal myotomy from a point 1 cm onto gastric cardia to inferior pulmonary vein
Muscle edges should separate by 1–2 cm
+/− antireflux procedure (controversy here but many surgeons will perform a partial wrap—Belsey, Dor, or Toupet)
Post-op UGI with gastrografin prior to feeding
Common Curveballs
Pt has a malignancy on endoscopy Pt won’t have classic manometry Pt will perforate after EGD Pt will have “megaesophagus”
Pt will have bad reflux post-op if you don’t do a wrap Pt will have bad PFTs and won’t tolerate a thoracotomy You perforate esophagus performing the myotomy (repair with absorbable suture and cover with wrap)
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Strikeouts
You forget the UGI, EGD, or manometry
You can’t describe the myotomy or forget to mention extending onto stomach
You get stuck in referring pt back to GI doc and in describing medical therapy and won’t take pt to the OR for myotomy
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