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Achalasia&Surgical Treatments

Thursday, April 2, 2009


Achalasia is a condition where the esophagus is unable to move food into the stomach. Although achalasia is relatively rare, Cleveland Clinic treats approximately two cases every week. Over the last seven years, we have treated more patients with achalasia than any other center in the United States. Cleveland Clinic also is one of the few centers in the world diligently researching its cause and treatment.

More Information

Cleveland_Clinic_Host: Welcome to our Online Health Chat with David Mason, MD. We are thrilled to have Dr. Mason here today for this chat. Let’s begin with some of those questions.

Speaker_-_Dr__David_Mason: Thank you for having me today. Let’s begin.

Achalasia Symptoms

cathyg: Is achalasia like MS where symptoms come and go?

Speaker_-_Dr__David_Mason: Achalasia is typically progressive and symptoms once present will likely persist.

Cleveland_Clinic_Host: We have approximately 15 minutes left in the chat. We will continue to answer questions, please use the 'ask' button to submit your question.

heathersock: I am 40 years old with achalasia and had the heller myotomy I still get chest pain – what’s next.

Speaker_-_Dr__David_Mason: Most patients improve markedly after surgery for achalasia. However symptoms do not always resolve despite what appears to be on all studies to be an excellent result.

Further testing including studies mentioned above may be in order if symptoms persist.

harrysmith: I have achalasia and had surgery about 5 years ago for this. Last month I had a heart attack. Both cause similar types of chest pain – how do you know how to identify the pain and what to do.

Speaker_-_Dr__David_Mason: If you have chest pain - you must first be evaluated for cardiac causes such as a heart attack first. Further evaluation can then be performed if this cardiac evaluation is normal.

cathyg: I have reflux and a sensitive stomach after heller surgery. Is there a pain med other than tylenol that can be taken that will not hurt your stomach?

Speaker_-_Dr__David_Mason: If the discomfort is related to reflux, a proton pump inhibitor such as protonix or nexium would best address this.

Achalasia Diagnosis

san174dy: Hi, in 2003 I was experiencing problems swallowing, did a barium swallow test, was told it was ok... later in 2006 had barium test prior to gall bladder surgery where tech saw a "spastic esophagus" but nothing was done about it... now in 2009 I have been to my family dr then I sought 2nd opinion from a /pulmonary dr (he believes I have achalasia). I have an appt at the Cleveland Clinic to see a GI dr. 4/3. I have done 2 breathing tests, been on 3 inhalers, 2 antibiotics, did a chest ct scan and 2 x rays. What do you think I should expect next to diagnose this? I thank you much in advance. Sandy

Speaker_-_Dr__David_Mason: The diagnosis of achalasia can be challenging. Work-up includes esophagram, esophageal manometry (testing of the "movement of the esophagus"),and endoscopy.

Achalasia Treatment

General Treatment Questions

katerine1949: My husband was just diagnosed with achalasia – what is the course of treatment. What foods do you suggest?

Speaker_-_Dr__David_Mason: Dietary modifications for achalasia are unlikely to resolve his symptoms. Management options include medicines, endoscopic balloon dilatation, and surgery. The specific treatment for your husband would need to be carefully evaluated with the tests mentioned earlier. Certainly treatment is quite patient specific.

wendy: What are all the treatments for achalasia and are there certain people that do better with certain types of treatments?

Speaker_-_Dr__David_Mason: Treatment for achalasia is individualized. Younger patients typically are referred for surgery early. Other options such as endoscopic balloon dilatation and botox injection might be attempted in older patients prior to referral for surgery.

Achalasia Treatment: Balloon Dilatation

carolina: What does balloon dilatation for achalasia involve?

Speaker_-_Dr__David_Mason: Balloon dilatation is a procedure performed with sedation typically as an outpatient. First, an endoscope is passed through your mouth to evaluate the esophagus. If a dilatation is recommended then a catheter is placed through the endoscope and inflated.

The procedure is brief - usually lasting about one half hour.

mrs_adam: My mother has achalasia for about 4 years now – about a year ago she had the dilatation and everything was great. Now everything is back – she is having difficulty swallowing again and has pain with swallowing. Is this common to get everything back like this – she is very depressed. Do people get multiple dilatation?

Speaker_-_Dr__David_Mason: Recurrence of symptoms and the need for repeated procedures in achalasia is common, however they can certainly be managed. Repeat balloon dilatation can be performed and is frequently performed and should improve symptoms. However, surgery for a more definitive treatment should be considered.

Achalasia Treatment: Heller Myotomy

kathyNV58: About 10 years ago, my husband underwent a laparascopic Heller myotomy and fundoplication, but the symptoms of his disease began to return 1 1/2 years later. His quality of life has continued to deteriorate – I would like him to get treatment but we are not sure there are things that would help him – what are other options?

Speaker_-_Dr__David_Mason: Achalasia can recur even after surgery. Re-do heller myotomy is one of several options. Significant evaluation would need to be performed in order to choose his best therapy. This would include manometry, endoscopy, and esophagram to start.

kjf52: My daughter had achalasia and had a laparoscopic myotomy, partial nissen, and g-tube placement about 6 months ago. she still has symptoms – cant swallow very well – what do you think? Does it get better over time – or should she get another opinion

Speaker_-_Dr__David_Mason: Symptoms are not always completely resolved after surgery for achalasia, although the results are typically quite good. At 6 months from her surgery, I would expect some improvement. I think it would be reasonable to consider another opinion.

walterw: What is involved in a heller myotomy and what is better – by open surgery or laparoscopically as far as outcomes?

Speaker_-_Dr__David_Mason: Achalasia is characterized by an abnormal relaxation of the valve at the bottom of the esophagus, called the lower esophageal sphincter. Heller myotomy involves cutting part of the muscle of this sphincter and loosening of this valve.

Heller myotomy can be performed laparoscopically in most patients who have not had previous abdominal surgery and is preferred over open surgery.

greenapple: What is recovery like for heller myotomy and when should you feel normal again – does the swallowing improve right away?

Speaker_-_Dr__David_Mason: Swallowing should improve right away after surgery for achalasia. Typically the surgery takes approximately three hours and most patients are discharged home the following day after surgery. One is typically back to normal activities within a few weeks.

greenapple: is there a difference between laparascopic and thorascopic myotomy

Speaker_-_Dr__David_Mason: Laparoscopic myotomy is performed using telescopes and minimally invasive instruments through an abdominal approach. Thoracoscopic myotomy is performed also using minimally invasive techniques but through the chest. Laparascopic myotomy is the preferred approach.

benny: I have been reading a lot online and some people mention Heller Myotomy with fundoplication wrap and some just call it heller myotomy – so are there different types and when do they decide to do the wrap vs. not

Speaker_-_Dr__David_Mason: Heller myotomy involves loosening the lower valve that causes achalasia. However, patients can have reflux after surgery due to this loosening. It is a necessary compromise.

Fundoplication can help prevent reflux after surgery for achalasia although it is debated amongst surgeons whether this is necessary. It is our preference at Cleveland Clinic to perform a partial fundoplication (slight re-tightening of the valve), which balances loosening of the valve with prevention of reflux.

Achalasia Treatment: Botox

bluemoon: How is botox related to achalasia – I was reading online and it was suggested that as a treatment

Speaker_-_Dr__David_Mason: Botox is a medicine that when injected into muscle can cause relaxation. When injected into the lower esophageal sphincter, which is responsible for achalasia, it can also cause relaxation. This allows passage of food and liquids.

In general, botox injections need to be repeated and are not generally the first line treatment of achalasia.

Achalasia Treatment: J-tube

cr1977ca: My uncle has had achalasia for some time. He has a jtube and it is very difficult for him – it often clogs and leaks and he is uncomfortable. What would you suggest – are there treatments he could get and have that removed?

Speaker_-_Dr__David_Mason: J Tube clogging is common. Minimization of pills placed through the j-tube could hopefully prevent some of this. Other treatments of achalasia include balloon dilatation, botox injection, and surgery. He could be assessed for these.

Reflux after surgery

cathyg: I had surgery for a last april. Am on Protonix twice daily. Not comfortable taking so much. Osteoporosis is in family. I am female 48 years old.

Speaker_-_Dr__David_Mason: Reflux after surgical treatment for achalasia can occur. Anti-reflux medications such as Protonix are often prescribed. I recommend discussion of the dose with your prescribing physician.

sab70: I have been diagnosed with GERD and Achalasia – can you explain both? Are they related? I have problems swallowing. Are the treatments the same?

Speaker_-_Dr__David_Mason: Because achalasia involves abnormality of the lower esophageal sphincter, reflux is still possible particularly after surgery to loosen this valve.

Further evaluation to determine the exact causes of your swallowing difficulties would need to be performed.

Follow-up after surgery

cathyg: should you have a barium swallow every year as a followup from heller myotomy or a scope?

Speaker_-_Dr__David_Mason: barium swallow after heller myotomy and endoscopy are standard practice at the Cleveland Clinic.

cathyg: My surgeon released me after follow-up from surgery. Is my GI dr knowledgeable enough to do all followups?

Speaker_-_Dr__David_Mason: Yes - a Gastroenterologist familiar with achalasia can follow you in the future.

Diet and Achalasia

larrydon: Barium test has been showed the closure of my Esophagus and I cannot swallow or drink easily unless by cold water pressure(ACHALASIA) - what I should do( like food,sport and so on) until I can get evaluated for treatment

Speaker_-_Dr__David_Mason: Many symptom complexes can be confused with achalasia. Confirmatory studies need to be performed. I recommend continuing with whatever eating regimen seems to best tolerate it. There are no activity restrictions.

tim_jr_45: Are there any foods or supplements you can take to help swallow better before you go for surgery? I have heard that taking certain enzymes or eating some types of juice can help you delay surgery. Also read about aloe vera and vitamin B

Speaker_-_Dr__David_Mason: Food supplements and vitamin supplements are unlikely to change the natural history of achalasia. If reluctant or unable to undergo surgery, balloon dilatation can first be attempted.

Prognosis after Achalasia Treatment

vicki62761: I have a 16 year old son with Achalasia. Heller Myotomy w/dor fund in 2007. I understand this is a degenerative disease, and obviously, I'm concerned about his future since he was diagnosed so young. Do you know if prognosis is better/worse with a younger person's diagnosis? Is it just a case by case basis?

Speaker_-_Dr__David_Mason: It is difficult to predict the long term course of your son's disease. If his symptoms are improved and he is doing well, these are excellent prognostic signs. Close follow up is certainly recommended by your surgeon or gastroenterologist.

cathyg: Have there been any studies to know what the percentage of progression is If your surgery for achalasia is successful?

Speaker_-_Dr__David_Mason: Outcomes and disease course after surgery for achalasia are clearly dependent on each individual patient's condition. This includes the condition of the esophagus at the time of surgery.

However, most people have excellent results after surgery with low remission rates.

Other Questions

cathyg: Is achalasia exacerbated by stress?

Speaker_-_Dr__David_Mason: The underlying cause for achalasia is uncertain. However, it does not appear to be related to stress.

vicki62761: My son also has Celiac Disease w/the Achalasia. I'm wondering about the autoimmune disease/Achalasia link. I realize the exact cause of A is unknown, but are you seeing an increase in patients with both?

Speaker_-_Dr__David_Mason: I have no experience with patients with celiac disease and achalasia and I am not aware of a link.

cathyg: Do you know of a support group for Achalasia patients?

Speaker_-_Dr__David_Mason: There are online support groups for achalasia. These sites may provide an opportunity for users with a common interest or health care issue to communicate and offer support. Statements are opinion only and are not considered medical advice.

has76: I started getting achalasia after the birth of my son – is there a relationship between childbirth and getting this condition?

Speaker_-_Dr__David_Mason: The diagnosis of achalasia can be confused with other esophageal and gastroenterology abnormalities. Increased abdominal pressure associated with pregnancy can exacerbate GI symptoms. Further evaluation to clarify the diagnosis of achalasia mentioned earlier should be performed.

myonlinecking_2: My father is 90 years old and has been suffering with swallowing problems for about 5 years. It has progressively gotten worse. Several visits to gastro doctors have produced no results. He currently has to put a thickener in the liquids he drinks to prevent the liquid from entering his lungs. His appetite is good and his health is fair. We believe that perhaps some minor strokes have caused this problem. His speech is ok but there are time when his words are not really clear. Is there any hope for him?

Speaker_-_Dr__David_Mason: It sounds as if your father is having aspiration (passage of food and liquids into his lungs) as opposed to into his esophagus, the normal pathway for food. There are many etiologies that cause aspiration - it is difficult to know what his are.

dandan: Can not swallow food or liquids. I had an endoscopy this week and they were able to get down liquids – what is this?

Speaker_-_Dr__David_Mason: You may have an esophageal motility disorder (a problem with the way the muscle of the esophagus squeezes). Manometry would be a reasonable next test. Manometry measures the coordination and strength of muscular squeeze in the esophagus.

gorge5: I have been choking a lot on food – I read a lot on the internet – maybe I have achalasia – is it something that progresses until it gets worse and surgery is needed or can you function without surgery – I am going to my doctor next week

Speaker_-_Dr__David_Mason: The diagnosis of achalasia requires multiple tests as I have mentioned. Choking on food can be caused by many problems, not only achalasia.

yoyo: I have esophageal rings – have you ever heard of that – I go in now and then to get it my esophagus dilated but is there a more permanent treatment.

Speaker_-_Dr__David_Mason: Esophageal rings or strictures have multiple causes. Depending on the severity surgery is sometimes an option. However, most can be managed with dilatation.

Cleveland_Clinic_Host: Thank you for being with us today Dr. Mason, we appreciate your time and attention to answering all these great questions.

Speaker_-_Dr__David_Mason: Thank you for having me.

Technology for web chats paid in part by an educational grant from AT&T Ohio and the AT&T Foundation (formerly SBC).

Reviewed: 04/09

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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