Achalasia
Achalasia is a chronic disorder of the oesophagus in which the lower oesophageal sphincter fails to relax properly, causing difficulty in swallowing. Treatment is aimed at relieving the spasm and improving oesophageal emptying. Options include Botox injection into the sphincter, endoscopic balloon dilatation, or a surgical procedure known as Heller’s myotomy. A/Prof Taylor specialises in the diagnosis and treatment of achalasia, offering a comprehensive range of therapeutic options tailored to each patient.
What is Achalasia?
Achalasia, also known as oesophageal achalasia, is a condition in which the oesophagus (a tube that carries food from the mouth to the stomach) is unable to move the food into the stomach. A lower oesophageal sphincter is a ring of muscle fibres that surrounds the lower-most end of the oesophagus where it joins the stomach. LES acts like a valve between the oesophagus and stomach, preventing food from moving backwards into the oesophagus. In people with achalasia, the LES fails to relax during swallowing, resulting in the food moving backwards into the oesophagus.
Symptoms of Achalasia
The main symptoms of achalasia include:
- Difficulty in swallowing (dysphagia),
- Regurgitation of food,
- Heartburn,
- Weight loss
- Chest pain
- Cough.
Diagnosis of Achalasia
Your doctor may order the following tests to diagnose achalasia:
- Barium swallow test: The test involves swallowing a barium preparation while X-rays are taken. The barium coats the walls of the oesophagus and stomach and makes the abnormalities visible more clearly.
- Endoscopy: This test allows the doctor to examine the inside of the patient's oesophagus, stomach, and portions of the intestine, with an instrument, called an endoscope, a thin, flexible, lighted tube.
- Manometry: It is a test that measures changes in pressure exerted by the oesophageal sphincter.
Treatment for Achalasia
Treatment options for achalasia include:
- Medications: Medications such as nitrates and calcium channel blockers are recommended to relax the lower oesophagus sphincter.
- Botox: Botulinum toxin injection can be administered to help relax the sphincter muscles
- Balloon dilation (pneumatic dilatation): A small balloon is positioned at the LES and inflated in order to widen the opening for food to enter the stomach.
- Myotomy: It is a surgical procedure in which the sphincter muscle is cut to allow the oesophagus to open.
Depending on your condition your doctor will decide which treatment is right for you.
What is Heller Myotomy?
Heller myotomy is a surgical procedure to open the tight sphincter muscle (LES) by cutting the thick outer muscle tissue between the esophagus and stomach. This is usually followed by a partial fundoplication to prevent reflux following the surgery. The surgery allows food to pass easily into the stomach.
The esophagus (food tube) passes food from the mouth to the stomach. A valve in the esophagus called the lower esophageal sphincter (LES), located at the junction of the stomach and esophagus, allows the passage of food to the stomach and prevents the receding of stomach acid back into the esophagus.
Achalasia is a condition that causes weakening of the upper esophageal muscles and prevents complete relaxation of the LES, making passage of food and liquids into the stomach difficult. These problems create difficulty in swallowing and can lead to weight loss, malnutrition, vomiting, and dehydration.
Pre-procedural Preparation for Heller Myotomy
You will have to be on a liquid diet for 3-4 days before the procedure in order to clear the esophagus completely.
Procedure of Heller Myotomy
Heller myotomy can be performed by a minimally invasive laparoscopic approach or an open approach. The procedure will be performed under the effect of general anesthesia. Your surgeon will make one long incision (of 6-10 inches or more)on your upper abdomen for an open surgical approach, or five to six small incisions for a laparoscopic approach. For the laparoscopic approach, your surgeon will insert tiny instruments and a laparoscope (a thin tube with a lighted device and a camera at the end to view the internal organs on a screen) through the small incisions.
Steps involved in Heller Myotomy procedure:
- Your surgeon will make a lengthwise incision in the food tube, from just above the LES slightly into the stomach tissues. Only the outer muscles of the esophagus will be cut, leaving the inner mucosal layer untouched. The incisions will reduce the force of the contracting muscles and relax the LES, thereby, allowing food to pass easily.
- This, however, makes it easy for the stomach acid to recede into the esophagus. Hence, a fundoplication is often performed along with myotomy.
- To perform the fundoplication, your surgeon will wrap the upper part of your stomach around the LES, like a collar, to strengthen it.
- Myotomy and fundoplication together will allow entry of food into the stomach and at the same time prevent the acid from refluxing back into the esophagus.
Post-Operative care
Following the procedure, you may be discharged after a day, if you have undergone a laparoscopic surgery or after several days in the case of open surgery. You may be advised to consume liquids and a soft food diet for a month. After fundoplication, you may be instructed to change your eating habits for a few months to help in the healing of the created esophageal valve.
Medications will be given for pain relief. Avoid strenuous activities, lifting heavy objects and driving for at least 2 weeks after surgery. Inform your doctor immediately if you experience fever over 101 degrees F, nausea or vomiting for 24 hours, constipation or diarrhea for over 48 hours, or swelling, redness and odorous drainage from the incisions.
Risks and Complications of Heller Myotomy
As with any procedure, Heller Myotomy involves potential risks and complications. They include:
- Damage to the esophagus, liver, stomach, spleen or lungs
- Infection and bleeding
- Perforations of the gastric or esophageal mucosal layer
- Recurrence of gastroesophageal reflux disease (GERD)
- Recurrence of original achalasia symptoms
