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Laparoscopic Myotomy for Achalasia

The esophagus (also called the gullet), is a muscular tube that moves food down to the stomach. There is a valve at the junction of the esophagus and stomach called the lower esophageal sphincter that normally relaxes when food passes through. The condition of achalasia occurs when there is a failure of relaxation of this sphincter. Food passage gets obstructed and there is difficulty in swallowing (we call this symptom dysphagia). Dysphagia is initially to solids and progresses on to affect liquids as well. Eventually the esophagus dilates as a result of this blockage.

If we suspect this, the best investigation is a gastroscopy, where we pass a long, thin, flexible telescope down the upper gastrointestinal tract. A barium swallow, a radiological study where contrast is swallowed while X-ray pictures are taken, can also diagnose this condition clearly. A manometry study to record the motility of the esophagus is sometimes also required to establish the diagnosis.

Achalasia is progressive and debilitating if not treated. There is no cause for this condition in the majority of true achalasia, but in our local experience, about 50% of patients who apprear to have achalasia actually have a malignancy causing the obstruction (what we call pseudo-achalasia). The first thing we need to do is to rule out conclusively that a cancer is not the actual problem. We may need to do a CT scan or even a diagnostic laparoscopy to be absolutely sure.

Some doctors try treating achalasia with medication or an injection of Botox through the endoscope to relax the sphincter. The results of these options are not long-lasting in our experience. Another endoscopic treatment is a forceful dilatation of the tight sphincter with a balloon passed through the scope. About 60-80% of patients will have good results after balloon dilatation. There is, however, a 5% risk of perforating the esophagus during dilation and a 20% chance that multiple sessions are required.

Many experts believe that surgery is the best treatment. However, this is a more invasive option and it is reasonable to try balloon dilatation first if you want to avoid surgery. Younger patients tend to do better with surgery rather than dilatation and it is our preference to offer surgery as a first-line treatment if you are young and fit for surgery. Surgery also tends to be less complicated if we offer this upfront compared to doing a salvage procedure for a patient that has failed dilatation and has a scarred esophagus.

The operation needed is called an esophageal myotomy, where the tight muscles of the sphincter is divided. The conventional way to do this is through a long opening in the rib cage or upper abdomen. We prefer a keyhole approach by a procedure called laparoscopic myotomy. We also combine this operation with a wrap of the top of the stomach around the esophagus to prevent reflux symptoms after surgery.

Most of our patients are admitted on the day of surgery and stay in hospital for 1-2 days after. Recovery is rapid as only small incisions are used compared to conventional open surgery. About 90% of patients will have excellent long term results.

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