Achalasia is a medical condition that affects the esophagus and lower esophageal sphincter (LES). The esophagus is a muscular tube that contracts and propels food from the mouth down to the stomach. The LES is a one way valve that relaxes and allows food to pass from the esophagus into the stomach. The LES prevents reflux of stomach acid back into the esophagus also. In achalasia, the LES fails to relax, and the muscles of the esophagus do not propel food from the mouth to the stomach. This results in dysphagia (feeling of food or liquid getting “stuck”), weight loss, and regurgitation. Over time, the esophagus dilates and may be associated with chronic cough or wheezing. The cause of achalasia remains unknown.
The advantages of a laparoscopic Heller myotomy include a smaller incision, less pain, shorter hospital stay, lower chance of future hernia formation, and earlier return to work and normal activities.
The most durable and effective treatment for achalasia is surgery. Endoscopic treatments such as balloon dilatation and injection of botulinum toxin are transient and usually reserved for patients who are not surgical candidates. Surgery for achalasia involves dividing the muscle fibers of the LES. This is performed laparoscopically with 5 small incisions (all < 1 inch), as opposed to the “open” surgery which may require a 10-12 inch incision. A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The muscle fibers of the LES are divided. This procedure is a Heller Myotomy and allows food to pass through the LES and into the stomach. After the Heller Myotomy is performed, a valve must be surgically recreated at the LES in order to prevent reflux of harmful stomach acids back into the esophagus. This is accomplished with a fundoplication. A fundoplication is a wrap of stomach that is gently placed around the lower portion of the esophagus. Two different types of fundoplication are performed including a Toupet or a Dor Fundoplication.
Previously, a Heller myotomy was completed through the chest and required a lengthy recovery in the hospital with a tube to drain the chest. Currently, the laparoscopic approach does not require a chest tube and provides a quick recovery with decreased pain.
A liquid diet is started the day after surgery and advanced to a soft diet as tolerated. Patients will need to continue on soft foods for approximately 2-4 weeks after surgery. Most patients spend one night in the hospital and are discharged home the next day. Most patients return to work in less than one week depending on the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.
Vaziri K; Soper NJ; Laparoscopic Heller Myotomy: Technical Aspects and Operative Pitfalls. Journal of GI Surgery, 2008, Jan 23 – ahead of print.