A 35-year-old woman presents with progressive dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium swallow shows a dilated esophagus with a tapered 'bird's beak' narrowing at the lower esophageal sphincter. High-resolution manometry confirms absence of peristalsis and incomplete LES relaxation. She has no prior surgical history. Which is the most appropriate definitive management?

• A Endoscopic botulinum toxin injection into the LES
• B Oral nitrates and calcium channel blockers
• C Laparoscopic Heller myotomy with partial fundoplication ✓
• D Pneumatic balloon dilation of the LES

Explanation

Laparoscopic Heller myotomy with partial (Dor or Toupet) fundoplication is the gold standard definitive treatment for achalasia, offering sustained symptom relief in over 90 percent of patients. Pneumatic dilation is an alternative but carries a perforation risk of 1-5 percent and is often reserved for poor surgical candidates. Botulinum toxin and pharmacotherapy are palliative options with limited durability, typically used in elderly or unfit patients.

Reference: Sabiston Textbook of Surgery, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.