The surgical treatment of achalasia is called a Heller myotomy. This is a procedure in which the muscles surrounding the lower esophagus are visualized and cut. Traditionally this surgery was performed through an incision in the chest or incision in the abdomen. Over the past decade the laparoscopic approach has gained favor as the preferred technique.
This is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to perform the myotomy through several tiny incisions, most of which are less than a half-centimeter in size. The concept of the surgery remains the same as the open approach. The esophageal muscles are visualized and cut while taking care to preserve the inner lining of the esophagus. Typically part of the stomach is then wrapped partially around the esophagus in order to prevent reflux symptoms. This is called Dor fundoplication or anterior wrap of the stomach. Recently, we have been using the robot to assist in this operation. It is the same operation as using the laparoscope but the robot allows for better visualization of the anatomy which may decrease the chance of having a complication from the operation. The advantages of this method include a shorter hospitalization, less pain, fewer and smaller scars, and a shorter recovery.
Laparoscopic or Robot assisted Heller myotomy is a safe and effective treatment for achalasia. However, in the presence of adhesions or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications. Other complications, although rare, include bleeding and infection. It is uncommon to require a blood transfusion for this operation. There is a small risk of perforation during the myotomy. There is also a risk of injury to the vagus nerve, liver, stomach, bowel, and spleen.
After laparoscopic surgery, most patients can take clear liquids next day and start a full liquid within 3 days, and return to a normal diet after 2 weeks. The typical hospital stay is 1-2 days, and many patients can return to work after two weeks. If the surgery is done open instead of laparoscopically, patients may need to take a month off work. Heavy lifting is typically restricted for six weeks or more.
Long Term Outcome
The Heller myotomy is a long-term treatment, and many patients do not require any further treatment. However, some will eventually need pneumatic dilatation, repeat myotomy (usually performed as an open procedure the second time around), or esophagectomy. It is important to monitor changes in the shape and function of the esophagus with an annual timed barium swallow. Regular endoscopy may also be useful to monitor changes in the tissue of the esophagus, since reflux may damage the esophagus over time, potentially causing the return of dysphagia, or a premalignant condition known as Barrett’s esophagus.
Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.