Achalasia surgery
|
Achalasia Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Achalasia surgery On the Web |
|
American Roentgen Ray Society Images of Achalasia surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Surgery
- Balloon (pneumatic) dilation, also called dilatation. The muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincter. Gastroenterologists who specialize in achalasia and have done many of these forceful balloon dilations have better results and fewer perforations than inexperienced ones. There is always a small risk of a perforation which would have to be fixed by surgery right away. Gastroesophageal reflux (GERD) occurs after pneumatic dilation in some patients. Pneumatic dilation causes some scarring which may increase the difficulty of Heller myotomy if this surgery is needed later. Pneumatic dilation is most effective on the long term in patients over the age of 40; the benefits tend to be shorter-lived in younger patients. This treatment may need to be repeated with larger balloons for maximum effectiveness.
- Surgery: Heller myotomy helps 90% of achalasia patients. It can usually be performed by a keyhole approach, or laparoscopically.[1] The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact. A partial fundoplication or "wrap" is added in order to prevent excessive reflux, which can cause serious damage to the esophagus over time. In a Dor (anterior) fundoplication, part of the stomach is laid over the esophagus and stitched in place so whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. After surgery, patients should keep to a soft diet for several weeks to a month, avoiding foods that can aggravate reflux.
- Bougienage
- A mechanical dilation of the LES with a firm rubber hose. This tends to be much more effective for patients with strictures than for achalasia.
- Balloon Dilation
- Also depends on ripping the LES.
- There is a fine line between achieving a good result and causing esophageal perforation (seen in 2-6%).
- Additionally, there are no guidelines concerning inflation time, number of inflations / session, inflation pressure, and how many sessions a patient should have before moving to another therapeutic modality.
- Approximately 60 –85 % of patients have good initial results. Unfortunately, 50 % of patients will require further therapy within the next 5 years.
- There is also data that suggests that repeated attempts are less likely to be successful and are associated with an increased risk of perforation.
- It appears that better results are associated with age > 45 years, patients with symptoms greater than 5 years, and in those with a mildly dilated esophagus.
- The other major side effect is the development of reflux esophagitis in ~ 2%.
- Surgical myotomy was first performed by Heller in 1913. The operation consisted of two myotomies on opposite sides of the esophagus performed through a laparotomy.
- The modified Heller approach (via left thoracotomy) has a success rate of 70–90%, and a mortality rate of 0.3% (similar to the 0.2% for pneumatic dilation).
- Reflux occurs in ~ 10%, and can be complicated by ulceration, stricture and the development of Barrett’s.
- There is little good data comparing surgery vs. pneumatic dilation, however surgery may have a higher rate of long-term benefit (95% vs. 65% at ~5 years).
- Surgery is a good option for younger patients (<40 years old) as balloon dilation is only 50% successful with the 1st treatment, and < 70% effective overall in this age group.
- It is also recommended for patients in whom dilation is especially risky (those with a tortuous distal esophagus, esophageal diverticula or who have had previous surgery of the gastroenterology (GE) junction), and those who have failed BoTox.
- The surgery can also be preformed laparoscopically or thoracoscopically, and early data suggests equivalent short term results when compared with the open procedure.