Surgery for Achalasia

If you suffer from difficulty swallowing you may have a condition called achalasia.  The treatments for this are:

• Oral medications
• Endoscopic esophageal dilation
• Botox injections in the distal esophagus
• Surgical cutting of the muscle of the distal esophagus (Heller myotomy)

First you need to have a clear diagnosis of achalasia made by your gastroenterologist or surgeon.  There are pros and cons to each of these procedures.

WHAT IS ACHALASIA ?

Achalasia is a rare disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.  Many patients also have abnormal or absent contractions of the esophagus above the obstructed distal esophagus.   Other symptoms may also include weight loss, chest pain, vomiting, difficulty swallowing and chronic aspiration.

WHAT CAUSES ACHALASIA?

The cause of achalasia is unknown.  Achalasia has effects on both the muscles and nerves of the esophagus; however, the effects on the nerves are believed to be the most important. Early in achalasia, inflammation can be seen under the microscope in the muscle of the lower esophagus, especially around the nerves. As the disease progresses, the nerves begin to degenerate and ultimately disappear, particularly the nerves that cause the lower esophageal sphincter to relax. Still later in the progression of the disease, muscle cells begin to degenerate, possibly because of the damage to the nerves. The result of these changes is a lower sphincter that cannot relax and muscle in the lower esophageal body that cannot support peristaltic waves. With time, the body of the esophagus stretches and becomes very enlarged (dilated).

HOW IS ACHALASIA TREATED?

GERD is generally treated in progressive steps:

1. ORAL MEDICATIONS

Oral medications that help to relax the lower esophageal sphincter include drugs called nitrates.  By themselves, oral medications are likely to provide only short-term and not long-term relief of the symptoms of achalasia, and many patients experience side-effects from the medications.

2. ESOPHAGEAL DILATION

The lower esophageal sphincter also may be treated directly by forceful dilation. The balloon is placed across the lower sphincter with the help of x-ray, and the balloon is blown up suddenly. The goal is to stretch--actually to tear--the sphincter. Patients in whom dilation is not successful can undergo further dilations, but the rate of success decreases with each additional dilation. The main complication of forceful dilation is rupture of the esophagus, which occurs 5% of the time. Death following forceful dilation is rare.

3. BOTOX INJECTION

Endoscopic injection of botulinum toxininto the lower sphincter to weaken it is effective.  Treatment with botulinum toxin is safe, but the effects on the sphincter often last only for months, and additional injections with botulinum toxin may be necessary. Injection is a good option for patients who are very elderly or are at high risk for surgery,  

4. SURGERY

Until recently, this surgery was performed using an open Heller myotomy, either through the chest or through the abdomen.  Modern Heller myotomy is normally performed using minimally invasive laparoscopic techniques, which minimize risks and speed recovery.

Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.

WHAT ARE THE ADVANTAGES OF THE LAPAROSCOPIC METHOD?

The advantage of the laparoscopic approach is that it usually provides:

• reduced postoperative pain
• shorter hospital stay
• faster return to work
• improved cosmetic result

ARE YOU A CANDIATE FOR THE LAPAROSCOPIC METHOD?

Although laparoscopic Heller myotomy has many benefits, it may not be appropriate for some patients. Your surgeon at University Surgeons Associastes in consultation with your primary care physician and/or gastroenterologist will determine if the technique is appropriate for you.

WHAT TO EXPECT BEFORE LAPAROSCOPIC HELLER MYOTOMY:

• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery.
• Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition.
• Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
• It is recommended that you shower with an antibacterial soap the night before or morning of the operation.
• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon and/or anesthesiologist has told you to take with a sip of water the morning of surgery.
• Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
• Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

WHAT TO EXPECT THE DAY OF SURGERY:

• You usually arrive at the hospital the morning of the operation.
• A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during surgery.
• Often pre-operative medications are necessary.
• You will be under general anesthesia - asleep - during the operation which may last several hours.
• Following the operation you will be sent to the recovery room until you are fully awake.
• Most patients stay in the hospital the night of surgery and may require additional days in the hospital.

HOW IS LAPAROSCOPIC HELLER MYOTOMY PERFORMED?

• In a laparoscopic procedure, your surgeon use small incisions (1/4 to 1/2 inch) to enter the abdomen through cannulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the cannula, giving the surgeon a magnified view of the  internal organs on a television screen.
• The entire operation is performed inside after the abdomen is expanded by inflating it with gas.
• Laparoscopic Heller myotomy involves cutting the overactive muscle at the junction of the esophagus and the stomach.  This myotomy extends several centimeters up on the esophagus and down on the stomach.
• If there is a leak in the innermost layer of the esophagus, the perforation may need to be sutured closed.
• After the myotomy is performed, frequently a portion of the stomach is sutured over the myotomy to reinforce the site and to hold it open.
• Your surgron then closes the small incisions.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED OR COMPLETED BY THE LAPAROSCOPIC METHOD?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that may increase the possibility of converting to the open procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

WHAT SHOULD I EXPECT AFTER SURGERY?

• Patients are encouraged to engage in light activity while at home after surgery.
• Post operative pain is generally mild although some patients may require prescription pain medication.
• Anti-reflux medication is usually not required after surgery.
• You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse.
• Call and schedule a follow-up appointment within 2 weeks after your operation

ARE THERE SIDE EFFECTS TO THIS OPERATION?

Studies have shown that the vast majority of patients who undergo the procedure have immediate significant improvement in their symptoms.

Long-term side effects to this procedure are generally uncommon.

• There is a small risk of perforation during the myotomy. A barium swallow is performed the day after the surgery to check for leaks.
• Some patients still have temporary difficulty swallowing immediately after the operation. This usually resolves as the swelling at the surgical site goes down.
• Occasionally, patients may require a procedure to stretch the esophagus (endoscopic dilation) or rarely re-operation.

WHAT COMPLICATIONS CAN OCCUR?

Although the operation is considered safe, complications may occur as they may occur with any operation.

Complications may include but are not limited to:

• perforation of the esophagus at the myotomy site
• adverse reaction to general anesthesia
• bleeding
• injury to the esophagus, spleen, stomach or internal organs
• infection of the wound, abdomen, or blood.
• other less common complications may also occur.

Your surgeon may wish to discuss these with you.  Your surgeon will also help you decide if the risks of laparoscopic Heller mytomy are less than non-operative management.

WHEN TO CALL YOUR DOCTOR

Be sure to call your physician or surgeon if you develop any of the following:

• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids