Controversies in Heller Myotomy

 In Achalasia Cardia surgical relief in the form of Heller's myotomy give the most long lasting relief from symptoms. There are a lot of controversies associated with  the procedure. We will be discussing these.

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Short Myotomy (1-1.5cm) on gastric wall Vs Long myotomy on gastric wall (3cm)

   Long myotomy has a significant less dysphagia but there is no difference in  postoperative chest pain, regurgitation or heartburn.

 

 

•Addition of Anti reflux procedure 

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•Partial fundoplication is recommended in most cases

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In the only randomized trial the addition of antireflux procedure decreased the incidence of reflux ninefold without having any impact on dysphagia

 

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Length of Myotomy-- 

Klatskin Tumor

Q Which of the following is the least common alternative diagnosis in a case of hilar Cholangiocarcinoma?
i) Carcinoma gallbladder
ii) Mirizzi Syndrome
iii) Idiopathic benign focal stricture
iv) Choledocholithiasis


Answer iv)
All of the above mentioned conditions can mimic as tumor of the confluence of bile ducts. Klatskin tumor is a diagnostic and therapeutic dilemma.
Carcinoma neck of the gall bladder can mimic this. The findings in favor of Carcinoma Gall bladder are irregular wall thickening, involvement of segment IV and V of liver.
Mirizzi syndrome is caused by impaction of stone in the CBD and can lead to periductal fibrosis
Idiopathic benign focal stricture or malignant masquerade are group of benign diseases of biliary tract and are very diificult to distinguish from carcinoma. In a suspected case of Klatskin tumor, resectional surgery without preop diagnosis is the accepted modality.