Patient Education and Consent
Before surgery for achalasia is undertaken, the patient's fitness for the procedure must be determined. A significant number of patients with chronic achalasia have weight loss in excess of 20 lb and may not be in ideal physical shape for surgery. In addition, loss of muscle mass in the upper chest may also limit the patient's ability to cough and to be weaned off the ventilator. A thorough evaluation of the patient by an internist may be necessary. In cases of severe weight loss, balloon dilatation may be used first to enable the patient to gain weight. In addition, any candidal infection must be treated before the surgical procedure.
Preprocedural Planning
Contrast esophagography
The preferred initial diagnostic test for most patients who present with progressive dysphagia is contrast esophagography. This inexpensive and readily available study often reveals the classic findings of a dilated esophagus, impaired peristalsis, and the pathognomonic smooth tapering at the esophagogastric junction (EGJ) commonly termed "bird's beak" esophagus.
If diagnosed early, the esophagus may be of normal caliber, though most patients present with some element of dilatation. Commonly, an air-fluid level forms as esophageal emptying is delayed, or the barium tablet or marshmallow "hangs up" just above the EGJ and may require several minutes to pass. Food particles are often seen despite patients' fasting for several hours prior to the study, indicating a significant delay in esophageal emptying. In long-standing achalasia, the esophagus can become dilated and tortuous and has been termed sigmoid-shaped or megaesophagus.
Manometry
Manometry is essential in making the diagnosis, with the vast majority of patients exhibiting the classic findings of incomplete lower esophageal sphincter (LES) relaxation and aperistalsis of the esophageal body. [16] In a minority of patients, manometry tracings show simultaneous contractions, often of normal amplitude, which some have referred to as "vigorous achalasia."
A common misconception is that the LES must also be hypertensive. Although the LES pressure can occasionally be elevated, most patients have normal LES pressures (< 45 mm Hg) with incomplete LES relaxation with deglutition. Unfortunately, manometry is not available in all centers, and many surgeons proceed to surgery without manometric findings. There are data to support the view that manometry is not needed in all cases of achalasia. [17]
Endoscopy
Endoscopy is necessary to exclude pseudoachalasia and to evaluate for atypical anatomy (eg, epiphrenic or traction diverticula). Characteristic endoscopic findings include a dilated esophagus with failure of the LES to open with insufflation and some mild resistance to passage of the scope through the EGJ, commonly described as a "pop." Retained food and debris in the esophagus are common. If suspicion of pseudoachalasia persists, endoscopic ultrasonography (US) with biopsy and computed tomography (CT) should be included in the evaluation. Endoscopy is also useful for obtaining samples to rule out candidal infection.
Patient Preparation
Positioning
Patients undergoing laparoscopic myotomy are placed in a modified lithotomy position. A beanbag is placed, and the arms are tucked at the sides. The surgeon stands in between the patient’s legs, and the assistant usually stands on the patient’s left side. Monitors are placed at the head of the bed, and one is placed on the right side of the patient so that the assistant can see the screen.
Monitoring & Follow-up
After undergoing surgery, the patient is kept on NPO (nil per os) status until a barium swallow is completed. This imaging study is done to ensure that the operation did not cause a perforation. Typically, patients receive liquids on the evening of their operation and then are advanced to a soft diet and discharged the following day. Nausea must be treated aggressively with antiemetics. Patients are advised to avoid strenuous activity and heavy lifting for 4-6 weeks. Most patients resume normal activities within 1-2 weeks and a regular diet within 2-6 weeks.
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Incisions for esophageal myotomy.
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Chest radiograph in patient with achalasia.
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Radiograph of barium swallow in patient with long-standing achalasia.
