Achalasia Surgery

What is Achalasia?

This is a condition of the esophagus where the Lower esophageal sphincter fails to relax. The lower esophageal sphincter is a high pressure zone at the junction of the esophagus and stomach to prevent acid from flowing up into the esophagus. Under normal conditions this sphincter remains tight only loosening after swallowing to allow food to enter the stomach. In achalasia the sphincter fails to relax or loosen causing food to remain in the esophagus.

What Symptoms Does A Patient Experience?

Dysphagia or “food sticking” in the esophagus is the initial and main symptom that patients experience. This is usually more pronounced with solid food than with liquids. As the disease progresses, patients will regurgitate undigested food, complain of bad breath and heartburn.

What Complications Can Occur?

Achalasia can actually lead to a patient developing cancer. There is an 8% chance that this will occur. Also the patient is at risk of developing bronchitis or pneumonia secondary to aspiration into the trachea (windpipe) while sleeping.

How Is It Diagnosed?

Achalasia is typically diagnosed with a combination of three tests. The first is an upper endoscopy, where a tube with a camera and light look into the esophagus. This test is done to make sure a narrowing in the esophagus or a cancer is not the cause for the blockage. An UGI or barium swallow is usually done as well. This is an x-ray in which the patient drinks barium to outline the esophagus. Typical findings include a dilated esophagus with a narrowing at the lower esophageal sphincter classically referred to as the “bird’s beak” appearance. (Figure 5). The gold standard to make the diagnosis is Esophageal Manometry. This study places a probe in the esophagus to measure pressure when the patient drinks a sip of water. The findings confirming the diagnosis are no relaxation of the lower esophageal sphincter AND the body of the esophagus with significant contractions.

Are There Nonsurgical Options To Treat Achalasia?

Multiple therapies have been employed in the past including medications, endoscopic dilatation of the lower esophageal sphincter, and Botox injection to paralyze the sphincter. These options work to varying degrees but none provide lasting relief and must be repeated multiple times.

How Does The Surgical Treatment Compare To Medical Therapies?

Surgical treatment shows excellent results 85% of the time with one treatment and fewer complications than endoscopic treatments. What does surgery involve?

Surgery for Achalasia is done laparoscopically in our practice and takes about 1-1.5 hours to perform with an overnight hospital stay. The treatment involves dividing the muscle that makes up the lower esophageal sphincter leaving the mucosa (inner lining of the esophagus) intact. A partial wrap of the stomach over the esophagus is then performed to protect the exposed mucosa and decrease or prevent reflux from occurring after surgery.

Are There Complications From Surgery?

Complications can occur after any operation, but ones specific to this surgery include:

  • Damage to other organs – spleen, stomach, colon, pancreas
  • Esophageal perforation – this can occur at time of surgery or be delayed 5-7 days from a partial thickness injury at the time of surgery. Performing the wrap as we do in our practice greatly diminishes this risk
  • Incomplete myotomy – failure to divide the muscle of the lower esophageal sphincter completely may fail to relieve the symptoms
  • Pneumothorax – this is defined as air in the chest cavity outside the lung. This can occur if this space is inadvertently entered during the dissection of the esophagus. It typically is an incidental finding and resolves within 12-24 hours without treatment needed.
  • Bleeding

Pre and Post-Operative Instructions for Achalasia (Heller Myotomy)

Before Surgery

  • Discuss with your surgeon treatment options and ask any questions you might have with regards to that treatment.
  • Sign consent for surgery confirming that you understand the potential risks and benefits of surgery and agree to proceed.
  • Complete pre-operative testing including blood work, EKG or other tests your physician may order
  • Clear liquid diet only for 48 hours prior to surgery. This will decrease the likelihood of solid food remaining in the esophagus at time of surgery, lower the risks of infection post operatively.
  • Shower with Hibiclense (anti-bacterial soap) the night before and morning of surgery to help decrease risk of wound infection. (It can be purchased at any pharmacy or may be given to you by hospital staff)
  • Do NOT eat or drink anything after midnight before surgery. The stomach needs to be completely empty prior to surgery.
  • Stop Aspirin 1 week prior, Plavix 10 days prior, and Coumadin (Wafarin) 5 days prior to surgery. Notify your surgeon if taking any other blood thinners for instruction on when to stop them.
  • Stop Smoking 1 week prior to surgery

Day of Surgery

  • Arrive at hospital at time instructed by office staff. A minimum of 2 hours prior to scheduled surgery time
  • Nurses will prepare you for surgery with an IV and any pre-op medications that have been ordered.
  • The anesthesiologist will talk to you about putting you to sleep in a room just outside the operating room.
  • After surgery you will go to the recovery room for about 1 hour where you will be watched closely as you continue to wake up. Family members are not allowed in at this time.
  • You will spend at least 1 night in the hospital.

After Discharge from the Hospital

  • You are encouraged to walk and resume light activity when you return home
  • No lifting over 20 pounds until you see your surgeon.
  • Take pain medications as needed to allow increased mobility.
  • Prevent constipation by drinking lots of fluid and if necessary taking a stool softener (Colace) or Milk of Magnesia as needed.
  • Schedule a post-operative appointment for 2 weeks after surgery. Do this the day you get home or soon thereafter for ease of scheduling.

Call Your Doctor If:

  • Persistent fever over 101 degrees F
  • Significant bleeding
  • Pain not relieved by medications or that is getting more severe
  • Persistent nausea and vomiting
  • Increasing redness or drainage from the incisions
  • If unable to eat or drink liquids
  • Constipation not relieved by stool softeners or Milk of Magnesia of 3 days duration
  • Persistent cough or increasing shortness of breath

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