Masters Program Foregut Pathway: Robotic Heller

Abstract

Achalasia is a rare esophageal motility disorder that is characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES). Achalasia can be classified into primary and secondary forms. The cause of primary achalasia is unknown, but may be attributable to the loss of ganglia within the esophageal myenteric plexus. Secondary achalasia can be isolated to the esophagus or part of a generalized motility disorder affecting other portions of the GI tract. While no cure currently exists for this disease process, all present-day therapeutic approaches aim to reduce the LES pressure. Achalasia therapy can be classified into non-surgical and surgical treatments. Non-surgical treatments include pharmacotherapy using calcium channel blocker and nitrates, injection of botulinum toxin, and pneumatic dilation. Commonly used surgical treatments for achalasia are peroral endoscopic myotomy and Heller myotomy. The focus of this chapter is the surgical treatment of achalasia by Heller myotomy. Preoperative patient evaluation includes a standard dysphagia questionnaire, contrast esophagram with upper endoscopy, and manometry to confirm achalasia diagnosis. The procedure is performed using a hybrid trans-abdominal laparoscopic approach with the myotomy performed using the da Vinci Surgical System. Patients typically stay overnight and are discharged on a soft diet. Most have significant relief of dysphagia immediately, but require long-term follow-up due to the nature of their disease.