Esophageal Disorders Achalasia | Gastroesophageal Reflux Disease (GERD, Acid Relux)
Achalasia is a disease in which the esophagus stops contracting and the valve between the esophagus and the stomach does not relax causing difficulty swallowing. Using the da Vinci robotic system to make tiny incisions in the abdomen allows the surgeon to cure the symptoms of achalasia in more than 95 percent of all patients.
The esophagus (the swallowing tube that goes from your throat to the stomach) is not a motionless organ. Quite the contrary, it is an active organ responsible for bringing the food to the stomach by contracting in a coordinated fashion, and moving food and liquids to the stomach. Achalasia is a disease of the muscle layer of the esophagus in which the esophagus stops contracting and the valve between the esophagus and the stomach does not relax. The combination of a non-functioning esophagus with a sphincter (valve) that does not open defines achalasia. In patients with achalasia, there is a loss of nerve ganglia in the esophagus. The cause of this is unknown in the majority of patents.
The most common symptom of achalasia is difficulty swallowing. The disease develops relatively slowly and in the beginning patients may fill only fullness in the chest area. Typically, symptoms progress and the difficulty swallowing get worse. Patients will feel difficulty with both liquids and solids, something that it is typical of achalasia. The great majority of patients will also report regurgitation of undigested food that is easily distinguished from vomiting. Other possible symptoms include heartburn in 15 to 25 percent of patients; aspiration of food to the lungs with recurrent aspiration pneumonias; chest pain or spasms .Left untreated, achalasia lead to severe weight lost and malnutrition.
Achalasia is suspected when a patient presents with typical history, but three tests are important confirming the diagnosis and excluding other diseases:
Barium swallow – This is a test in which the patient drinks a liquid (barium), and x-rays are taken showing the progression of the liquid in the esophagus. In patients with achalasia, a typical birds beak sign is present (figure 1).
Manometry – This test measures the contraction of the esophageal muscle. The typical findings are an esophagus that does not contract and a lower esophageal sphincter that does not relax. It may be the most important test in patients with achalasia.
Upper endoscopy – The endoscope is a small flexible tube that is inserted into the esophagus and it allows the examination of the whole esophagus and stomach. It is important to exclude other disease processes that can be confused with achalasia.
Balloon dilation – Also known as pneumatic dilation, this treatment involves the stretching of the lower esophagus with a special balloon, in the hopes of disrupturing the muscle fibers in the lower esophagus. It is successful in improving symptoms in 65 to 90 percent of patients and may be more effective in patients who are older than 45. The procedure may need to be repeated, but it becomes less effective at improving symptoms. The main drawback is the possibility of perforating the esophagus, requiring a large chest incision to fix it.
Injection of botulinum toxin – This is a special toxin that prevents muscle contraction. It can be injected in the muscle of the non-contracting esophageal sphincter. It is effective in 76 percent of patients and with time, a second injection will be needed. After two to three years, all patients will have a recurrence of their symptoms.
Robotic Assisted Heller Myotomy – The use of the da Vinci robotic system allows the surgeon to cure the symptoms of achalasia in more than 95 percent of all patients. It is done through small tiny incisions in the abdomen. With the patient asleep under general anesthesia, the surgeon uses the robot to find the lower esophagus and cut the thickened muscle (myotomy) that does not relax. Because of the superior optics and maneuverability of the robotic arms, complications such as perforation that were seen with laparoscopy are avoided. The disruption of the sphincter may cause acid reflux, and to prevent it, we routinely perform a Dor antireflux procedure with the robot. Most patients go home on the morning after surgery and resume normal activities in approximately one week.