A 28-year-old woman presents with progressive dysphagia to both liquids and solids over two years, with occasional regurgitation of undigested food and weight loss. Barium swallow shows a dilated oesophagus tapering to a bird-beak appearance. High-resolution manometry shows absent peristalsis with an elevated integrated relaxation pressure. What is the definitive surgical treatment?

• A Thoracoscopic division of the lower oesophageal vascular supply
• B Transthoracic oesophagectomy with gastric pull-up
• C Nissen fundoplication alone
• D Laparoscopic Heller cardiomyotomy with a partial fundoplication ✓

Explanation

Type I achalasia is defined manometrically by absent peristalsis with impaired LES relaxation. The standard surgical operation is a Heller myotomy, dividing the circular muscle fibres of the lower oesophagus and cardia for about 6 cm on the oesophagus and 2 cm onto the stomach, combined with a partial (Dor or Toupet) fundoplication to prevent reflux. Nissen fundoplication alone does not address the non-relaxing sphincter, and oesophagectomy is reserved for end-stage mega-oesophagus or failed myotomy.

Reference: Sabiston Textbook of Surgery, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.