What is Achalasia
Achalasia is a rare swallowing disorder. There are two main problems:
- The muscles of the lower oesophagus (the passage from your mouth to your stomach) do not
work effectively and your food is not pushed down into your stomach.
- The muscle sphincter at the lower end of your oesophagus, which should open to allow the
food into your stomach and prevent it flowing backwards, does not function effectively.
What are the symptoms of Achalasia?
Achalasia generally has a slow onset and tends to gradually worsen over time. The main symptoms are:
- difficulty swallowing;
- vomiting and regurgitating food immediately after a meal;
- unintentional loss of weight;
- chest pain that is worse after a meal;
- feeling full after only a small amount of food;
- coughing due to food and fluid entering the windpipe and lungs.
For more information on Achalasia please see the Oesophageal Patients’ Association information leaflet on the condition. It contains lots of relevant information. https://www.opa.org.uk/downloads/achalasia/patient-guide-to-achalasia-2018.pdf
What are the main treatment options?
The main treatment options are:
- Balloon dilatation
- Surgery – Heller’s laparoscopic cardiomyotomy
- Botox injections
- Per-oral Endoscopic Myotomy (POEM)
1. Balloon dilatation
The muscle at the lower end of your oesophagus can be stretched or dilated using a special balloon during the endoscopy and will relieve symptoms for many people. Treatment may have to be repeated more than once.
The procedure can be performed under sedation or a general anaesthetic. An endoscope is gently passed down into your oesophagus and any residual food or fluid will be suctioned away. A guidewire is passed down through the endoscope, the endoscope is removed, then the balloon is passed over the guidewire into the correct position. The balloon is then inflated for a short time, approximately 2 minutes, then deflated and removed.
The endoscopist then looks at the area again with the endoscope to check everything is satisfactory.
What are the complications of balloon dilation?
- Chest infection or pneumonia if food or fluid residue is inhaled into the lungs.
• Bleeding due to a crack or damage.
• Acid reflux because the muscle sphincter will now be relaxed and may allow stomach acid to leak back up into the oesophagus.
• Perforation of the oesophagus – luckily this is uncommon (2-3%). But if it occurs it will mean admitting you to hospital to treatment with intravenous fluids and antibiotics and in severe cases, surgery to repair the damage.
2. Laparoscopic Heller’s cardiomyotomy
The Heller myotomy is a laparoscopic (minimally invasive) surgical procedure used to treat achalasia. It is essentially an esophagomyotomy, the cutting the esophageal sphincter muscle, performed laparoscopically. The operation’s success rate is very high and usually permanent. A small number of patients may need additional treatment.
In the procedure, several tiny incisions are made and a small scope inserted, through which miniature surgical instruments are passed. The scope is connected to a video camera which then sends a magnified image to a monitor, allowing the surgeon to envision the anatomy and manipulate the instruments.
The advantages of the Heller myotomy include:
- Less post-operative pain
- A 1-2 day hospital stay vs. up to a week with a conventioonal open procedure
- Faster recovery from surgery
- A more rapid return to work and normal activities
Please see this surgical video of Mr Griffiths performing a laparoscopic Heller’s myotomy https://vimeo.com/190615380
3. Botox injections
Botox injections are used in achalasia in patients who are not suitable for other treatments due to old age or fitness reasons. The botox drug is injected at endoscopy and it relaxes the lower oesophageal sphincter muscle to improve the patients’ swallowing. It generally lasts around 3 months, but in some patients it lasts longer. It’s a very safe treatment for achalasia, but is only a temporary solution.
4. POEM procedure
Mr Griffiths doesn’t currently perform the POEM procedure as he feels that the rates of post-procedure reflux disease are very high (up to 40-50%) and otherwise it has very few advantages over the more conventional laparoscopic Heller’s procedure. He is happy to discuss this option in the outpatient clinic and can refer to other surgeons who offer this procedure in other cities. It appears to have particular benefit in patients with Type 3 achalasia or patients who have recurrent achalasia after Heller’s myotomy.