This document summarizes a presentation on the surgical treatment of achalasia given at the 2012 SAGES Annual Meeting. It provides background on achalasia, including epidemiology and etiology. It discusses current treatment options and their outcomes, with surgical myotomy shown to have the highest long-term success rate of 92%. The presentation explores ongoing controversies in surgical treatment and also discusses emerging endoscopic options like per oral endoscopic myotomy. It emphasizes that patient selection and surgical technique are two key predictors of outcome for treating achalasia.

1. Surgical Treatment of Achalasia
Update
Foregut: Dysmotility from Mouth to Anus
SAGES Annual Meeting
March 7, 2012
San Diego, CA
C. Daniel Smith, MD, FACS
1

2. Conflict of Interest / Disclosure
• No financial or other relationship with
any product or treatment discussed in
this talk
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 2

3. Achalsia - Background
• First described in 1674 - food blockage
inside the esophagus
• Term Achalasia coined in 1927 by Arthur
Hunt - Greek for lack of relaxation
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 3

4. Achalsia - Epidemiology
• Incidence 0.03-1.0/100,000 per year
• Prevalence < 10/100,000
• Occurs at any age
• Peak incidence 20-30 years and 60-70
years
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 4

5. Achalasia - Etiology
• Unknown cause
• Destruction of myoenteric plexus
responsible for esophageal peristalsis
and normal LES function
• Possibly related to inflammatory or
autoimmune process
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 5

6. Achalasia - Diagnosis
• Dysphagia, regurgitation, chest pain
• EGD with normal mucosa (may see
some stasis changes) - “pop”
• Classic contrast swallow - birds beak
• EMS - absent peristalsis and non-
relaxing LES
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 6

7. Achalasia - Treatment
Eliminate esophageal outflow restriction
• Safe
• Effective
• Durable
• Limit side effects
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 7

8. Achalasia - Treatment
Pharmacologic
• Smooth muscle relaxation
Mechanical
• Botox
• Pneumatic dilation
• Cardioesophageal myotomy
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 8

9. Achalasia - Treatment Outcomes
Early 1 Year Long-term
Success Success Success
Botox 80% 50% <20%
Dilation 80% 50% <20%
Myotomy 98% 95% 92%
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 9

10. Achalasia - Surgery Controversies
Issue
Chest or abdomen Abdomen
Extent of myotomy 2-3 below GEJ (sling fibers)
Wrap or not Wrap
Toupet or Dor Toupet
Postop or intraop test Intraop preferrably with EGD
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 10

11. Achalasia - Surgical Failure
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 11

12. Achalasia - Esophagogastric Myotomy
• Adequate anterior
myotomy - 6 cm
proximal and 2-3 cm
distal (sling fibers)
• Intraoperative
endoscopic
assessment - adequacy
and mucosal integrity
• Accompanying antireflux procedure - partial
wrap
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 12

13. Treatment of Achalasia - Stenting
Diseases of the Esophagus (2010) 23, 361–367
DOI: 10.1111/j.1442-2050.2010.01048.x
• PRCT
• 155 patients
• Stent in place for 4-5
days
• Patients followed at 6
month intervals
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 13

14. Treatment of Achalasia - Stenting
Diseases of the Esophagus (2010) 23, 361–367
DOI: 10.1111/j.1442-2050.2010.01048.x
stent
92% success
pneumatic dilation
66% success
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 14

15. Treatment of Achalasia - Stenting
• Provocative concept
• China only stent
• Results too good to be
true?
• Difficult to reproduce in
US with current stents
available
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 15

16. Treatment of Achalasia - POEM
Per-Oral
Endoscopic
Myotomy
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 16

17. Treatment of Achalasia - POEM
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 17

18. Treatment of Achalasia - POEM
Stavropoulos
n 12
Op time 150 min
Myotomy length 5.5 cm
LOS 2.2
F/U 9.5 mon
Success 11/12
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 18

19. Treatment of Achalasia - POEM
Swanstrom - JACS 2011
n 18
Op time 156 min
Myotomy length 9 cm
LOS 1.1
F/U 6 months
Success all improved
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 19

20. Treatment of Achalasia - POEM
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 20

21. Treatment of Achalasia - POEM
Inoue - Endoscopy 2010 (n=17)
Inoue - DDW
n 100
Op time 113 min
Myotomy length 14 cm
LOS 5.9
F/U short-term
Success “good”
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 21

22. Treatment of Achalasia - POEM
• Promising new
technique
• Gaining traction at
select centers
• ? advantages over
existing surgical
myotomy
• ? controlling GERD
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 22

23. Two Predictors of Outcome
Patient Selection
Operative Technique
Surgical Rx Achalasia. Foregut PG CRS.
SAGES Annual Meeting. Mar 7, 2012 23

24. Surgical Treatment of Achalasia
Update
Foregut: Dysmotility from Mouth to Anus
SAGES Annual Meeting
March 7, 2012
San Diego, CA
C. Daniel Smith, MD, FACS
24