Laparoscopic Heller Myotomy for Type II Achalasia

Oscar M. Crespin, MD; Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD


March 26, 2013

Progressive Dysphagia in an Adolescent Boy

Achalasia is an esophageal motility disorder characterized by the absence of peristaltic contractions and by impaired relaxation of the lower esophageal sphincter (LES) in response to swallowing. The disease presents in different forms that can be distinguished by manometric findings and other clinical characteristics.

Surgery is very effective in the treatment of achalasia, but occasionally it fails to improve the presenting dysphagia. A new manometric classification of esophageal achalasia has recently been proposed that differentiates the types of achalasia and may correlate with the final outcomes of treatment.[1]

Case Presentation

The patient is a 17-year-old boy whose dysphagia began 1 year ago. His dysphagia became progressive to liquids, leading to a significant accumulation of secretions. Furthermore, he has experienced episodes of regurgitation in the past 3 months. Two previous botulinum toxin injections did not relieve his symptoms.

High-resolution manometry (HRM) showed an LES pressure of 55 mm Hg, a residual pressure of 20 mm Hg, and 100% failed contractions with panesophageal pressurizations (Figure 1).

Figure 1. High-resolution manometry showing the lower esophageal sphincter with elevated resting and residual pressures and no peristaltic contractions with panesophageal pressurizations, consistent with type II achalasia.

An upper gastrointestinal series showed a mildly dilated esophagus with "bird beak" at the end. The esophagus contained residual food, but no masses or ulcerations consistent with achalasia were found (Figure 2).

Figure 2. Upper gastrointestinal series showing a mildly dilated esophagus with "bird beak" at the end.

Esophagogastroduodenoscopy showed a slightly dilated esophagus containing residual fluid (Figure 3).

Figure 3. Esophagogastroduodenoscopy showing a mildly dilated esophagus.

We decided that the best options for treating this patient were laparoscopic Heller myotomy and a Toupet fundoplication.