Minimally invasive surgery for esophageal achalasia

functional esophageal disorder to require surgical intervention.The first account of a successfully treated case of achalasia was described by Thomas Willis in 1674, in which a whale bone was used to forcibly dilate the cardia.The first surgical myotomy was performed by Ernst Heller in 1913. PATHOPHYSIOLOGY AND ASSESSMENT OF ACHALASIAFailure of the lower esophageal sphincter to completely relax upon swallowing results in a functional obstruction and pressurization of the esophageal body.Defective esophageal emptying progressively leads to dilatation and tortuosity of the esophagus with loss of the peristaltic waveform.Overall deterioration of esophageal function and structure with time, and the fact that peristalsis can return after surgical myotomy, suggest that the motor abnormalities secondary to esophageal outflow obstruction may be reversible and that early definitive treatment of achalasia is essential to preserve esophageal function [1] .Achalasia has an insidious onset.Dysphagia and food regurgitation are the two major presenting symptoms of the disease.Nocturnal regurgitation often leads to recurrent episodes of aspiration pneumonia.In about 40% of patients the diagnosis of achalasia is delayed by the reported symptoms of chest pain and heartburn simulating gastroesophageal reflux disease.As the disease progresses, inability to swallow causes malnutrition and weight loss.Squamous-cell carcinoma of the esophagus appears to develop with greater frequency in patients with long-standing achalasia than in the normal population [2] .The most sensitive tests for detecting achalasia a r e e s o p h a g e a l m a n o m e t r y a n d b a r i u m s wa l l ow videofluoroscopy.Aperistalsis and incomplete lower esophageal sphincter relaxation are the typical manometric features.Radiological abnormalities include aperistalsis, esophageal dilatation, and minimal lower esophageal s p h i n c t e r o p e n i n g w i t h a b i r d -b e a k a p p ea r a n ce.Endoscopic assessment is important to exclude the diagnosis of malignancy-induced secondary achalasia, often referred to as pseudoachalasia, before invasive therapies are implemented.Clinical features suggesting a tumor of the gastroesophageal junction are a short duration of dysphagia, a significant weight loss, and an elderly patient.Since adenocarcinoma of the cardia may present endoscopically as an infiltrating lesion with apparently normal mucosa, CT scan, endoscopic ultrasonography, and even exploratory laparoscopy should be used liberally in this subgroup of patients [3] .