Overview of achalasia treatment
Achalasia treatment aims to open up the tight ring of muscle at the lower end of the oesophagus (food pipe) so that food can pass into the stomach again, and the options are stretching (dilatation) and keyhole surgery. Achalasia itself is a rare disorder of movement in the oesophagus, and its cause is not fully understood.
The main symptom is difficulty swallowing: first with liquids, later with solid food as well. Over time, eating becomes harder and harder, and people lose weight. In achalasia, the pressure in the lower oesophageal sphincter (the ring of muscle between the oesophagus and the stomach) is very high. Normally this muscle relaxes when you swallow, but in achalasia the high pressure stops food from passing into the stomach, so it stays in the oesophagus. All the treatment options work on this one muscle ring: they aim to lower the pressure so that the passage into the stomach opens again.
Who is it for?
Treatment is planned once the diagnosis has been confirmed. Achalasia is often hard to diagnose at first, and the symptoms point the way. In advanced cases, a gastroscopy shows a widened oesophagus with leftover food. A contrast X-ray (barium swallow) shows a widened oesophagus that narrows like a bird's beak where it joins the stomach. The diagnosis is confirmed by measuring the pressure in the oesophagus (manometry).
Once achalasia is diagnosed, there are two main treatment options:
- Stretching (dilatation): the lower sphincter is widened during an endoscopy. The effect wears off over time.
- Surgery: this is considered when stretching has not helped enough, or chosen directly in suitable patients. If you have had stretching before, there should be a gap of three months before the operation.
Which achalasia treatment is chosen depends on your symptoms, the findings of the tests and any treatment you have had before, and it is decided together with you.
Risks
Like any operation, achalasia surgery carries general risks, such as bleeding, infection, reactions to the anaesthetic and blood clots. There are also risks that are specific to this operation. Because the muscle layer is cut right down to the inner lining of the oesophagus, the lining can be injured during the operation; this is usually noticed and repaired straight away.
Once the tight muscle ring no longer closes the passage, stomach contents can flow back up more easily, which can cause reflux. This is why a fundoplication, the same wrap used in reflux surgery, is added to the operation. In some people, difficulty swallowing may not settle completely or may return over time, and further treatment may then be needed.
Preparation
Before the operation, you will have the tests needed to confirm the diagnosis, and, depending on your age and health, blood tests, a chest X-ray and an ECG (heart tracing). If you have had stretching before, the operation is planned with a gap of three months.
Tell your surgeon about all the medicines you take, especially blood-thinning medicines, because some may need to be stopped for a while. Because food can stay in the oesophagus in achalasia, you may be asked to follow a liquid diet for a short time and not to eat or drink for a set time before the operation, as your team advises. If you smoke or drink alcohol, you will be advised to stop. Finally, the possible risks and benefits are discussed with you and you give your written consent.
What happens
On the day
The operation is done by keyhole (laparoscopic) surgery, under general anaesthesia, so you are asleep throughout. The surgeon works through small cuts in the abdomen, watching an enlarged image from a camera on a screen.
At the lower end of the oesophagus, the whole muscle layer is cut along a length of 5 to 6 cm, so that the sphincter no longer narrows the passage (myotomy). To help prevent reflux, the upper part of the stomach (fundus) is also placed over the exposed area and fixed in position (fundoplication).
Aftercare
After the operation, your diet is usually built up step by step, starting with fluids and moving on to soft and then solid food, as your team advises. Eat slowly and chew well while the area heals. You will be encouraged to get up and walk soon after the operation, and you can return to your usual activities gradually, as you feel able. As part of your follow-up, a routine blood test check is done at 6 months.
When should you contact your doctor?
Contact your doctor straight away if you have:
- a high temperature or shivering (chills)
- severe or increasing pain in the chest or abdomen
- vomiting that does not stop
- being unable to swallow fluids
- redness, swelling or fluid leaking from any of the cuts
- shortness of breath