What Is Achalasia?
Achalasia is a condition that affects the Lower Esophageal Sphincter (LES). The sphincter is a muscle that controls the passage of the food between the esophagus and the stomach. In achalasia, the LES doesn’t completely relax and the passage of food is compromised.
Achalasia is a rare condition that affects around 3,000 people in the United States per year. Most patients are diagnosed between the ages of 25 and 60 years old.
What Causes Achalasia?
The cause of achalasia is not completely understood. Some attribute the lack of muscle relaxation in the lower esophageal sphincter to a neurological problem. Others have considered a genetic component. The reality is that at the time of this writing the true etiology of achalasia is not known.
Symptoms Of Achalasia
Most patients with achalasia complaint of dysphagia or difficulty swallowing. The symptom usually starts gradually and continues to progress with time. The typical patient will start noticing difficulty swallowing certain solids like chicken breast, turkey breast, bread, and hard vegetables. With time the patients will start noticing difficulty swallowing liquids. Many patients won’t seek medical attention until the symptoms are advanced. Many will compensate by eating slowly, chewing the food longer, eating standing up or sitting really straight.
Other patients will complain of chest pain when eating, regurgitation of undigested food of several days prior or bad breath (halitosis). Some will mention chronic cough at night with a significant lack of sleep due to aspiration of undigested food. In severe cases, patients can be significantly underweight and malnourish.
How It Is Diagnosed?
The first step in the diagnosis is a good history and physical exam. In patients with the above symptoms, the diagnosis is usually suspected.
An Upper GI Series or Barium Swallow Test is usually the first test performed. It is a cheaper and non-invasive test. The classic findings are a very narrow passage of contrast through the lower esophageal sphincter and proximal dilation of the esophagus.
An EGD or Upper Endoscopy is another commonly perform test in patients with achalasia. Patients with esophageal cancer, esophageal strictures from chronic reflux or upper stomach cancer can have a similar presentation to achalasia. This is called pseudoachalasia or secondary achalasia, so making a distinction is very important. The endoscopy can also be used for the treatment of achalasia.
The gold standard test in the diagnosis of achalasia is a High-Resolution Esophageal Manometry or an Esophageal Motility Study. This test is usually mandatory in order to confirm the diagnosis of achalasia. During the test, an electrode is placed in the esophagus and the patient is given something to swallow. After ten swallows the electricity generated by the esophagus is measured and the diagnosis is made. The classic findings for achalasia are, a hypertensive or tight lower esophageal sphincter that doesn’t relax with every swallow and lack of peristalsis (contractions) of the body of the esophagus.
Esophageal achalasia is irreversible but the symptoms can be significantly improved with treatment. Several temporary and more permanent treatment options are available. The treatment options are not aimed at improving the function of the esophagus. They are targeting the lower esophageal sphincter so the passage of the food to the stomach is improved. Below we will discuss some of the treatments used to weaken the sphincter muscle.
- Medications: This is the least effective treatment for achalasia. The medications normally used are nitrates and calcium channel blockers. These are medications used for blood pressure and cardiac conditions. They also relax the lower esophageal sphincter but the effect is minimal and they can have unpleasant side effects like headaches and low blood pressure.
- Botox: Injection of botox in the sphincter via endoscopy can be a good short term treatment for mild cases of achalasia. Botox will relax the sphincter and subsequently improving the symptoms. The effect is usually short-lived and frequent injections are needed. The other issue can be increase scarring of the muscle due to frequent injections and inflammation. This can make surgical therapy more difficult in the future. Botox injections are usually reserved for patients that cannot undergo surgery or myotomy.
- Balloon Dilation: A pneumatic balloon (see picture below) is passed through the lower esophageal sphincter during an endoscopy. The sphincter muscle is then serially dilated. By breaking down some of the muscle fibers the symptoms improve. Unfortunately, like Botox, the dilation is also short-lived and continuous treatments are usually required. The trauma and inflammation produced by the intervention can make surgery more difficult in the future. Serious complications can also happen after dilation. Esophageal perforations can be seen in 2-5% of the patients undergoing dilation. Just like Botox, balloon dilation is recommended for patients that cannot have more permanent solutions like surgery and myotomy.
- Heller Myotomy: A myotomy is the division of the muscle fibers using surgical techniques. In Dr. Caban’s practice, the surgery is done laparoscopically or minimally invasive. The success rate for this surgery is around 80-90 percent. A Heller Myotomy is usually performed in conjunction with a partial fundoplication in an attempt to minimize the chance of reflux after dividing the muscle. A Myotomy is the treatment of choice for esophageal achalasia.
- Peroral Endoscopic Myotomy: POEM is a Heller myotomy but performed endoscopically or through the mouth. When done by an expert endoscopist the procedure can have a similar success rate to the surgical counterpart. Because is done through the mouth several advantages can be seen. Less pain, fast recovery, lack of general anesthesia and ambulatory procedure are some of these advantages. Unfortunately, adverse effects can be seen with this type of therapy. Because this is a new procedure, long term data is limited. The centers were this treatment can be performed is limited because lack of robust endoscopic instrumentation and significant endoscopic expertise is needed. Another big drawback is the post-procedure reflux. Many patients will develop reflux and eventually needing surgical fundoplication to improve the reflux.
Esophageal Achalasia Surgery Recovery
What Happens After Heller Myotomy?
Because the operation is done minimally invasive the patient will experience less pain, faster recovery and faster return to regular activities when compared to an open procedure.
After surgery, you will be in the recovery room for 2-3 hours. You will be admitted to the hospital admission for 1-2 days. Your diet will be advanced slowly, the first day after surgery you will be on clear liquids and day two on full liquids. You will be discharged home on a full liquid diet for 2 weeks. After that, you will be on a soft diet for two more weeks. Once you have completed the 4 weeks of the liquid and soft diet you should be able to tolerate regular food.
Some patients can experience difficulty eating certain foods even after surgery because of the chronic damage to the esophageal motility that happens with Achalasia. This is more pronounced in patients that suffered from achalasia for a long period of time before seeking surgical treatment.
You will follow up with Dr. Caban in 2-3 weeks and at 3 months after surgery.
Most patients that have office type job can expect to return to work after 1-2 weeks. For those of you that have a heavy labor job were heavy lifting more than 15-20 pounds is necessary, you should account for 4-6 weeks out of work.
What People are Saying
“Dr. Angel Caban performed my surgery almost 5 years ago on 6/2/2014. He is a kind doctor and always treated me fairly. I always felt welcome in his office. I recommended him to many over the past 5 years”.
“Me encanta no lo cambio. Exelente el doctor caban y su personal. Muy buen grupo”.
“Another successful experience”
“Dr. Caban did my colon resection and did an outstanding job all the way across the board. I highly recommend him as well”.
“Very fortunate to have him”
“I have the privilege of working with Angel M Caban in the hospital environment. I also have had him be the surgeon to one of my family members. I would like everyone to know that he is a great surgeon. We are fortunate to have him here in Ocala. He is personable, easy to talk too and has excellent bedside manners”.
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