American Board of Internal Medicine (ABIM) Certification Practice Exam

What is the surgical treatment of choice for achalasia after myotomy?

1. Endoscopic ultrasound therapy

2. Fundoplication

3. Pneumatic dilation

4. Day surgery

The correct answer is: Fundoplication

The surgical treatment of choice for achalasia after a myotomy is fundoplication. Achalasia is a condition characterized by the failure of the lower esophageal sphincter to relax, leading to dysphagia and other gastrointestinal symptoms. A myotomy, which involves cutting the muscle at the lower esophageal sphincter, is often performed to relieve this obstruction. However, after myotomy, there is a risk of gastroesophageal reflux disease (GERD) due to the altered dynamics of the esophagus and stomach. Fundoplication is a procedure where the top of the stomach is wrapped around the lower esophagus to prevent reflux. This helps maintain the integrity of the junction between the esophagus and stomach after the myotomy and significantly reduces the risk of reflux, making it an important adjunctive procedure following myotomy. Other options, such as endoscopic ultrasound therapy, pneumatic dilation, and day surgery, do not play a primary role after myotomy for achalasia when considering long-term management of associated conditions like GERD. Fundoplication specifically addresses the potential complications that may arise from the myotomy, thereby making it the preferred choice in this context.