Achalasia

Achalasia is a motility disorder of the esophagus without a definitive cause.  The esophagus normally works by pushing food down into the stomach after a person swallows.  In achalasia, the esophagus doesn't work well or at all.  Some common symptoms are difficulty swallowing, feeling like food gets stuck when a patient tries to swallow.  A patient may experience vomiting of undigested food, where the food looks like it was when they first swallowed it.  They may feel symptoms of heartburn.  Usually it starts with difficulty swallowing solid food and can progress to difficulty with liquids.

Several tests lead to suspicion of Achalasia.  An upper endoscopy, where a camera is advanced down the esophagus, may show an esophagus that is dilated and doesn't move or squeeze.  This is lack of peristalsis.  There may be food remaning in the esophagus long after a patient has eaten.  The GE junction, or the muscle valve between the esophagus and stomach may be very tight.  An upper gastrointestinal series, or Upper GI, or esophagram is a study where a patient swallows liquid contrast and a video is taken as they swallow.  It may show a dilated esophagus that doesn't move and a narrowing at the GE junction.  This narrowing may be referred to as a "birds beak."  The diagnostic test, test that diagnoses achalasia, is Esophageal Manometry.  This is where a narrow tube is advanced down to the bottom of the esophagus and it measures the pressure in the esophagus the whole way down after swallowing.  This is performed by a gastroenterologist.

While there are several nonsurgical treatments available such as certain medications, botox injections at the GE junction during endoscopy and dilations of the GE junction, these are usually reserved for patients who are not very good surgical candidates or are trying more conservative measures first.  These options don't usually work for very long periods of time and can have side effects.  More definitive treatment is a Heller myotomy, which we perform robotically laparoscopically with a fundoplcation.  A heller myotomy involves cutting and separating the muscles of the end of the esophagus and the top of the stomach to open up the tight narrowing at the GE junction.  This surgery allows food to go into the stomach.  A fundoplication is a wrap of the top of the stomach around the valve at the bottom of the esophagus to prevent reflux or heartburn and keep the muscles from coming back together.  Although there is no cure for Achalasia, the purpose of the surgery is to be able to eat normally without the symptoms of difficulty swallowing and vomiting.