Achalasia

Achalasia is the best known primary motility disorder of the esophagus. It is characterized by failure of esophageal body peristalsis and incomplete relaxation of the lower esophageal valve. The abnormalities is caused by degeneration of some of the nerves of the lower part of the esophageal wall which causes loss of the ability to swallow food properly at the lower end of the esophagus. The cause of the condition is obscure. Patients with this condition have difficulty swallowing or dysphagia and most of them have regurgitation of food contents. Sometimes this condition can cause respiratory symptoms because the contents that are regurgitated up the esophagus go down into the airway passages and then cause chest infection.

Achalasia is diagnosed by having an upper GI series using Barium which demonstrates a dilated esophagus with an acute narrowing or Bird’s beak difformity at the lower end of esophagus. These patients also often have endoscopy which reveals residual liquid or food in the esophagus. In order to definitively establish the diagnosis of achalasia, manometry pressure measurments of the esophagus is carried out and demonstrates that there is an elevated pressure at the lower end of the esophagus and incomplete relaxation of the valve. Treatment of this condition is either by balloon dilatation or surgery. Recently, the use of a botulinium toxin has been used the treatment of achalasia; however, patients that respond to this treatment often get recurrences. Balloon dilatation can be done as an outpatient with minimal recovery time. It is less likely to be effective than surgical treatment and frequently needs to be repeated.

Surgical treatment of achalasia is the only definitive way to treat this condition. All surgical procedures employ a variation of Heller’s myotomy in which the circular muscle of the lower esophagus is divided. This can be carried out either through the chest or abdomen. Regardless of the route chosen, the important principles are that there should be an adequate myotomy, minimal hiatal disturbance, anti-reflux protection without the creation of obstruction and prevention of closure of the myotomy with healing.

This can be done either open as in conventional surgery or using the laparoscopic approach. Usually in addition to dividing the muscle at laparoscopy it is necessary to perform an anti-reflux procedure.

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