From the Guidelines
The preoperative workup for achalasia should include a comprehensive diagnostic evaluation, comprising clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, as recommended by the most recent guidelines 1.
Key Components of Preoperative Workup
- A thorough clinical history to establish the quality and severity of symptoms
- Upper endoscopy to rule out pseudoachalasia due to malignancy and assess esophageal dilation
- Timed barium esophagram to show structural changes and confirm outflow obstruction
- High-resolution manometry, the gold standard for diagnosing achalasia, to demonstrate incomplete lower esophageal sphincter relaxation and absent peristalsis
Additional Considerations
- Endoscopic functional luminal impedance planimetry (FLIP) as a useful adjunct test, particularly in cases with equivocal diagnosis 1
- CT scan of the chest and abdomen to evaluate for complications and rule out extrinsic compression
- Laboratory tests, including complete blood count, comprehensive metabolic panel, coagulation studies, and electrocardiogram, to assess overall health status and surgical risk
- Pulmonary function tests and cardiac evaluation as needed, based on patient-specific factors
Importance of Comprehensive Evaluation
A comprehensive preoperative workup is crucial to confirm the diagnosis, determine the subtype of achalasia, rule out alternative diagnoses, and prepare the patient for the appropriate surgical intervention, such as per-oral endoscopic myotomy (POEM) or laparoscopic Heller myotomy with partial fundoplication 1.
Recent Guidelines and Recommendations
Recent guidelines emphasize the importance of a comprehensive diagnostic workup, including clinical history, upper endoscopy, timed barium esophagram, and high-resolution manometry, as well as the consideration of adjunct tests like FLIP 1.
Patient-Specific Factors
Patient-specific factors, such as age, comorbidities, and surgical history, should be taken into account when determining the optimal treatment approach and preoperative workup 1.
From the Research
Preoperative Evaluation for Achalasia
The preoperative evaluation for achalasia involves several diagnostic tests to confirm the diagnosis and assess the severity of the condition. These tests include:
- Endoscopy to rule out other conditions such as esophageal cancer 2
- Barium swallow study to evaluate the esophageal motility and morphology 2
- High-resolution esophageal manometry (HRM) to assess the esophageal pressure and motility [(2,3)]
Diagnostic Algorithm
The diagnostic algorithm for achalasia involves a step-by-step approach to confirm the diagnosis and assess the severity of the condition. This includes:
- Clinical evaluation to assess the symptoms and medical history 3
- Endoscopic and radiographic evaluation to rule out other conditions [(2,3)]
- Manometric evaluation to assess the esophageal motility and pressure [(2,3)]
Treatment Options
The treatment options for achalasia include:
- Medical therapy with calcium channel blockers or nitrates [(4,5)]
- Endoscopic botulinum toxin injection [(4,2)]
- Pneumatic dilation [(4,2,6)]
- Laparoscopic Heller myotomy with partial fundoplication [(4,5,6)]
- Peroral endoscopic myotomy [(2,6)]
- Esophagectomy as a last resort for patients who have failed prior therapeutic attempts 6
Patient Selection and Management
Patient selection and management involve assessing the patient's overall health and selecting the most appropriate treatment option. This includes:
- Evaluating the patient's age, sex, and medical history 2
- Assessing the patient's symptoms and severity of the condition [(2,3)]
- Discussing the treatment options and risks with the patient [(3,6)]