Heller's myotomy is for Rx of:

Ans. c (Achalasia cardia). (Ref. Bailey & Love, Surgery, 25th/pg. 1036)ACHALASIA CARDIA# Achalasia is a motor disorder of the esophageal smooth muscle in which the LES does not relax normally with swallowing, and the esophageal body undergoes nonperistaltic contractions. It is due to loss of the ganglion cells in the myenteric (Auerbach's) plexus,# C/f: Dysphagia appears early, occurs with both liquids and solids, and is worsened by emotional stress and hurried eating.# Two types:- Primary: is idiopathic- Secondary: Chagas' disease; Trypanosoma cruzi, Gastric carcinoma that infiltrates the esophagus (pseudoachalasia), Lymphoma, Certain viral infections, Eosinophilic gastroenteritis, and certain neurodegenerative disorders.# Ba swallow (initial test of choice):- Megaesophagus/sigmoid esophagus.- "Bird beak" deformity on barium swallow study is characteristic.- Absence of primary peristalsis below level of cricopharyngeus.- Hurst phenomenon (temporary transit through cardia when hydrostatic pressure of Ba column is above toxic LES pressure).# CCK which normally causes fall in sphincter pressure,paradoxically causes contraction of LES (CCK test) (Cholecys- tokinin) .# MANOMETRY is best investigation for diagnosis.0# Vigorous achalasia is numerous tertiary contractions in non-dilated distal esophagus of early achalasia.# Rx: Treatment is by either endoscopic dilatation or surgical myotomy (Heller's myotomy). Pneumatic dilatation with a 30-mm balloon, the incidence of perforation should be less than 0.5%. The risk of perforation increases with bigger balloons, and they should be used cautiously for progressive dilatation over a period of weeks. Forceful dilatation is curative in 75-85% of cases. The results are best in patients aged more than 45 years. Myotomy is successful in more than 90% of cases and may be used after failed dilatation. Botulinum toxin by endoscopic injection into the LOS may be tried.