Questions and Answers About Achalasia
By Dr. Thomas Rice
Hello my name is Thomas Rice. I’m an esophageal surgeon, a general thoracic surgeon at the Cleveland Clinic and I’d like to talk to you about achalasia.
Achalasia is a peculiar disease that results in your inability to transport food from your mouth to your stomach. It comes about by immune damage of the involuntary nerves of the esophagus. This is probably a viral or possibly an autoimmune event where the T-cells (the same cells that cause transplant rejection) are activated to recognize the nerves of your esophagus as foreign. Over time, those nerves are destroyed and you lose the ability to transport food from your mouth to your stomach. What happens is that as you swallow, food packs into the lower end of your esophagus, and when your esophagus gets full enough it will empty partially.
The treatment of this disease does not bring about normal swallowing, but it does turn the esophagus into a passive conduit. Surgical treatment opens up the lower valve (lower esophageal sphincter) so that food passes from your mouth to your stomach by gravity. That’s a bit of a problem because that valve is there to stop the return of gastric contents into your esophagus. So the treatment of achalasia is balancing the destruction of that valve versus reflux. Every patient who I operate on gets a double procedure of a myotomy (a division of the valve) and a fundoplication to stop reflux. In the majority of the people, this can be done laparoscopically (laparoscopic Heller myotomy) through five small incisions in an operation that takes about an hour-and-a-half to two hours to do.
After that operation, you spend a night in the hospital. The next morning barium is administered during the barium swallow test to ensure that there is no leakage. The patient starts on a soft diet and goes home usually the day after the surgery. I usually see you one week after the operation to make sure your wounds are healing well. Then your diet is advanced to include other foods, and at eight weeks we do the crucial evaluation to make sure the esophagus is emptying adequately. But I have to prove that you do not have reflux, that the anti-reflux procedure - the Dor fundoplication - that was constructed was satisfactory to prevent reflux. If I find that there is any reflux, the patient will be managed with a proton pump inhibitor medication - usually at night because gravity will keep them free of reflux through the day.
Because this procedure does not restore normal esophageal function, but provides palliation, it is important to follow the emptying of the esophagus for life. And usually, I have my patients return annually for a timed barium swallow to ensure that emptying is adequate and there’s no damage from reflux. When necessary, we perform barium esophageal manometry to ensure that the complication of a reflux stricture is not present.
Although achalasia is a risk for developing cancer squamous cell cancer, it is quite a small risk. So the annual follow-up is usually not directed at cancer surveillance.
Thank you for your attention. If I can help you with the treatment of your achalasia, I’d be happy to do so.
Reviewed: 04/11
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