Type II Achalasia: Contemporary Diagnostic and Therapeutic Management

2 Oct 2025 16:00 17:30
Belgrade
Aleksandar Simic Host

Patient Profile & Clinical Presentation

  • Patient: 54-year-old male

  • History: Two and a half years of progressive retrosternal dysphagia for both solids and liquids.

  • Symptoms: Frequent episodes of regurgitation and heartburn, as well as minimal, clinically insignificant weight loss.

  • Previous Management: Initially referred by a gastroenterologist, where he had been wrongly treated for presumed gastroesophageal reflux disease due to symptoms of heartburn and regurgitation.

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Timed Barium Esophagogram (TBE)

  • Esophageal Findings: Markedly dilated esophagus.

  • Lower Esophageal Sphincter: Typical “bird’s beak” narrowing at the lower esophageal sphincter.

  • Contrast Retention: Significant contrast retention after 5 minutes, consistent with impaired esophageal emptying.

Upper GI Endoscopy

  • Dilated esophagus with food retention.

  • Resistance at the gastroesophageal junction.

  • No evidence of mucosal lesion or mass.

  • Hill Grade: I.

High-Resolution Manometry (HRM)

  • Panesophageal pressurization.

  • Aperistalsis.

  • Findings fulfill diagnostic criteria for type II achalasia.

MDCT

  • No malignancy or extrinsic esophageal compression.

  • Patchy or diffuse areas of hazy increased lung attenuation (Ground-glass opacities (GGO) were present), highly suggestive of aspiration-related inflammation.

Surgery

  • Approach: Minimally invasive laparoscopic surgery.

  • Hiatal Dissection: Limited hiatal dissection.

  • Procedure: Heller myotomy with accentuation of the angle of His.

Postoperative Follow-up

  • Postoperative course was uneventful and control esophagogram was done on postoperative day one.

  • Discharge two days post-surgery.

  • Two years after surgery, patient remained symptom free with significant clinical relief, with occasional minimal dysphagia for solids, which was sustained on routine yearly follow-up evaluations.

  • Routine upper GI endoscopy one and two years post-surgery: no recurrence of the disease.

Panel for Discussion

Aleksandar P. Simić (Belgrade, Serbia) | Pietro Familiari (Rome, Italy) | Christian Gutschow (Zurich, Switzerland) | Rehan Haidry (London, UK) | Stefan Mönig (Geneva, Switzerland)

Topics for Discussion

  1. Contemporary diagnostics

    • Importance of TBA and HRM

    • Current Position of FLIP

    • Will you perform MDCT in all pts prior to treatment?

  2. Question of pseudoachalasia

    • Importance of medical history

    • When is MDCT mandatory

  3. Primary choice of treatment

    • BD vs POEM vs HELLER

    • What to do in the younger patients (less than 40 years old)

    • Tailored approach?

    • Type III – Did POEM become the “Gold Standard”?

  4. Importance of antireflux procedures

    • POEM & TIF – Is this the future?

    • Significance of limited hiatal dissection

    • Type of fundoplication

    • Accentuation of the His angle – Is it enough?

  5. Benefits of robotic surgery for achalasia?

    • Pros

    • Cons

    • Is robotic going to replace laparoscopic surgery?

  6. Redo for failed treatment

    • Importance of BD

    • Importance of specialized centers where all the treatment modalities are available

  7. Treatment of sigmoid esophagus

    • Is myotomy enough?

    • When is esophagectomy necessary?