Achalasia is a progressive motility disorder of the oesophagus. Although symptoms may be temporarily improved by restricting dietary intake, ultimately the condition deteriorates. It becomes very difficult to swallow, regurgitation and other problems including aspiration and chest infections might occur. There are no drugs which are effective. Endoscopic treatment is available, but only provides short-term relief of symptoms, and may result in bad reflux symptoms as a permanent side-effect.
Surgery divides the abnormally tight lower oesophagus sphincter muscle fibres allowing swallowing to substantially improve. A fundoplication can also be performed at the same time which limits reflux. Overall this procedure, which is performed by keyhole surgery provides the best long-term outcomes.
The operation is carried out by keyhole surgery. Five small incisions (2x12mm; 3x5mm) are made in the abdomen, and the area around the lower oesophagus and upper stomach is freed up (mobilised).
Very carefully the longitudinal oesophageal fibres (run vertically up and down) are teased apart for at least 5cm above, and 2cm below the junction of the oesophagus and stomach. This then reveals the circular (go around like a ring) muscle fibres, and it is these which are abnormally tight. With great care these fibres are divided along the entire length. This releases the inner lining of the oesophagus (mucosa) which bulges forward. This is a paper-thin layer of tissue and it is very important not to damage it. This part of the operation is known as a laparoscopic myotomy or Heller’s procedure.
In some cases, the myotomy might be enough to deal with the symptoms of achalasia, but in most occasions, and to prevent excessive reflux, a fundoplication will also be performed.
Because the oesophagus is weak, a partial fundoplication is usually performed. Usually, a small portion of the front of the upper stomach (fundus) is used, and this is gently sutured to the front of the oesophagus creating a wrap of about 90-degrees. This is often referred to as a Dor fundoplication, and hence the entire operation is sometimes called the Heller-Dor procedure. It takes about 2-hours to perform and under general anaesthetic.
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After the operation, a contrast swallow is performed, and providing this is satisfactory, drinking fluids can commence, followed by soft or mousse diet. This should be continued for about 6-weeks after the operation to allow the oesophagus to accommodate the new configuration.
After this period, a normal healthy and diet can then be started, but advice is to always chew food well and drink plenty of fluids. The oesophagus itself remains weak, the surgery has simply released the overtight valve at the bottom.
Most patient can go home 1-3 days after surgery, and general recovery is rapid as the procedure is performed by keyhole surgery.
The procedure does involve intentional disruption to the muscles layer of the oesophagus, and the inner layer (mucosa) of the oesophagus can be damaged. This is known as a perforation. It is rare, but the risk is higher if endoscopic intervention has previously taken place. In most cases the perforation can be repaired at the time of surgery.
Swallowing may still be a problem in some patients, but this can be related to the background dysmotility which is still present. Mild reflux symptoms might occur depending on the balance between the myotomy, fundoplication and peristaltic function of the oesophagus.
The small risks of common to any operation including bleeding, infection, thrombo-embolic events and those related to a general anaesthetic.
Surgery is generally very effective at improving swallowing yet preventing reflux. Further intervention is rarely required.
The long-term results are very good with substantial and long-term improvements in quality of life and wellbeing.
