1. Treatment options for Achalasia David Rattner, MD

2. Options for Achalasia Treatment Balloon Dilation Balloon Dilation Botox Botox Heller Myotomy Heller Myotomy –Laparoscopic –Thoracoscopic –Open –Endoscopic

3. Key Technical Elements for Myotomy Variety of methods work Variety of methods work –Hook, scissors, blunt? Avoid Thermal Injuries Avoid Thermal Injuries –Control bleeding with pressure or epinephrine Confirm adequacy of myotomy Confirm adequacy of myotomy –2 cm below anatomic GE junction –Proximal extent less important –Intra-op endoscopy->”gun barrel view” –r/o perforation with leak test

4. Fundoplication: Why not? Historical Historical –Heller didn’t –Ellis Series- Lahey Clinic –If done “properly” very few have reflux Possible obstruction or angulation by wrap Possible obstruction or angulation by wrap Disrupts posterior Esophageal attachments Disrupts posterior Esophageal attachments Adds OR time Adds OR time

5. Why Fundoplication? Prevents Acid Reflux Prevents Acid Reflux –Late peptic stricture –?Barrett’s risk –Cost effective (PPI use plummets)

6. Mega-Esophagus If Myotomy-> no Fundoplication

7. Reflux Following Lap Heller U Toronto Study Surg Endosc 2005 U Toronto Study Surg Endosc 2005 –60% of pts tested had reflux if no fundoplication Vanderbilt Study Ann Surg 2004 Vanderbilt Study Ann Surg 2004 –47% if no fundoplication –9% if Dor Fundoplication Cleveland Clinic Study J TCVS 2005 Cleveland Clinic Study J TCVS 2005 –Reflux 7x more common if no fundoplication

8. Symptoms of Reflux are Meaningless! 23% of “asymptomatic” patients in Toronto Series had positive pH studies 23% of “asymptomatic” patients in Toronto Series had positive pH studies McGill Study –Surg Endosc 2006 McGill Study –Surg Endosc 2006 –12.5% had reflux following Heller + Dor –No correlation between GERD-HRQL and 24hour pH studies

9. Dysphagia and post op Manometry – Why test? FACT: Fundoplications raise resting LESP following myotomy FACT: Fundoplications raise resting LESP following myotomy FACT: Fundoplications raise residual LESP following myotomy FACT: Fundoplications raise residual LESP following myotomy FACT: Esophageal emptying is similar with and without Fundoplication FACT: Esophageal emptying is similar with and without Fundoplication FACT : No correlation between dysphagia score and LESP or Δ LESP FACT : No correlation between dysphagia score and LESP or Δ LESP WHY? WHY? –Peristalsis –Multifactorial/ behavioral

10. Proper Construction of the Dor Fundoplication

11. Heller + Toupet

12. Which Fundoplication? Dor or Toupet are equivalent Dor or Toupet are equivalent –Dor » if repairing perforation »In Thin patient Toupet may angulate GE Junction –Toupet- theoretic and aesthetically attractive –Liberal use of intraop endoscopy –Surgeon Preference NOT NISSENS !!!! NOT NISSENS !!!! –Too much impedance to forward flow –Highest re-operative rate –Nissen side effects

13. Future options Endoscopic Heller Myotomy Endoscopic Heller Myotomy

14. Conclusions Partial Fundoplications should be performed routinely Partial Fundoplications should be performed routinely Construct the fundoplication carefully and be capable of doing both anterior and posterior wraps Construct the fundoplication carefully and be capable of doing both anterior and posterior wraps Mega esophagus a special case Mega esophagus a special case