2026 New Edition ABSITE Sample Question

Answer and Explanation

Did you get it right? The correct answer is D, Heller esophagomyotomy with Dor fundoplication.

This patient has an esophagogram with the classic finding of a “bird-beak” appearance, suggesting achalasia.

Due to the high long-term success rate of operative management, surgery should be considered as first-line therapy for good operative risk candidates, especially in young patients less than 40 years old. Operative management consists of distal (Heller) esophagomyotomy through both the longitudinal and circular muscle layers.

This procedure can be performed laparoscopically in most instances. The addition of a partial fundoplication, such as a Dor or Toupet, helps to prevent postoperative reflux symptoms. It is important to note that a complete (Nissen) fundoplication is contraindicated in patients with an esophageal motility disorder such as achalasia, and only a partial wrap should be performed. Esophagectomy is rarely performed in achalasia but may be indicated in cases of end-stage disease with a tortuous (megaesophagus) or sigmoid esophagus.

Per-oral endoscopic myotomy (POEMS) is a novel approach by which the myotomy is performed endoscopically via a submucosal tunnel. It is currently unknown if the long-term results are comparable to Heller myotomy.

“Bird-beak” appearance (red arrow) due to dilated esophagus on barium swallow study.

Incorrect Answer Explanations

Answer A, calcium channel blockers: Medical treatment includes calcium channel blockers or nitrates to relax the lower esophageal sphincter (LES) and can provide symptom relief in the short-term. However, results are often limited by side effects, and patients have poor long-term outcomes on medical therapy alone, generally requiring definitive surgical management for symptom control.

Answer B, Botox injection: Botox injections into the LES often require repeated treatments as symptoms recur more than half of the time within 6 months. Botox is a good treatment choice for high-risk patients (for example, the elderly or comorbid), as it is the least invasive option.

Answer C, pneumatic dilation: Pneumatic dilation has comparably high success rates compared with myotomy; however, patients frequently require repeated interventions.

Answer E, Heller esophagomyotomy with Nissen fundoplication: Although a Heller myotomy is the first-line therapy for good operative risk candidates, a Nissen (360-degree) fundoplication is contraindicated due to the patient’s esophageal dysmotility. A partial wrap, such as a Dor or Toupet, should be performed instead.

Bottom Line

Esophagomyotomy should be considered as first-line therapy for good operative risk candidates with achalasia, especially in young patients less than 40 years old. A partial (not complete) wrap such as a Dor or Toupet fundoplication is generally performed concurrently to reduce the rates of postoperative reflux.