Thoracoscopic Versus Laparoscopic Modified Heller’s Cardiomyotomy for Achalasia of the Cardia

Abstract

Achalasia is a primary idiopathic esophageal motility disorder, the main presentation in patients with achalasia is dysphagia to both solids and liquids associated with regurgitation of undigested food or saliva, other associated symptoms include weight loss, substernal chest pain, and sometimes heartburn which may lead to the patient be misdiagnosed as GERD. The pathological hallmark of the disease is loss of ganglion cells in the myenteric plexus of the esophageal body and the LES. Although the etiology of this degenerative process is unknown, it ultimately leads to loss of the inhibitory neurotransmitters nitrous oxide and vasoactive intestinal peptide and as a result, imbalance between excitatory and inhibitory neurons occurs. This results in unopposed cholinergic activity that leads to incomplete relaxation of the LES and aperistalsis. The diagnosis of Achalasia is suggested by history and clinical picture, and confirmed by investigative tests. The Endoscopic appearance of pinpoint cardia and retained secretions, and the classic bird’s beak sign in Barium esophagogram don’t preclude manometric study which is the most important in reaching the final diagnosis, and is particularly beneficial in differentiating between GERD, Achalasia, and other motility disorders. The classic manometric findings are incomplete relaxation of the lower esophageal sphincter (LES) and absence of esophageal peristalsis.