Primary Cardiomyotomy Surgery

Elective surgery to correct symptoms of a diagnosis of Achalasia which may or may not have previously been treated with botox or pneumatic dilation

Achalasia surgery is very low-volume, however fundamentals of investigation, diagnosis and surgical technique have significant ‘cross-over’ with other hiatal procedures. We recommend patient management of this condition in those units that fulfil hiatal surgery service recommendations

Minimum investigation set

OGD/Contrast swallow and high-resolution manometry

Pass all patients through a hiatal MDT prior to surgery to achieve consensus diagnosis of achalasia

All patients should have had discussion about botox injection/pneumatic dilatation and be made aware POEM is an alternative treatment option although at present limited availability

Enter data into a registry to audit outcomes

Laparoscopic conversion to open < 5%

Adequate myotomy is defined as at least  >5cm on oesophagus and >2cm on stomach (below GOJ)

Less than 24 stay for Laparoscopic Cardiomyotomy > 90%

Readmission rates within 30 days <10%

Morbidity <5%

Mortality < 0.1%

Although there is some evidence of increased risk of SCC with achalasia no specific recommendation for routine follow up surveillance OGDs

Recurrent achalasia should be managed by a high-volume hiatal unit within a region that has experience of pneumatic dilation and POEM

Hiatal MDT Core Representation: ≥2 Surgeons/Gastroenterologist/Radiologist/Clinical Scientist or equivalent (healthcare professional running pH/manometry service) and Specialist Nurse