2005

Esophageal Motility Group Is Major Referral Center for Achalasia Surgery

Achalasia is a disorder of the esophagus characterized by swallowing difficulties and episodic regurgitation. Symptoms range from inconvenient -- unusually long mealtimes -- to life endangering if food is aspirated into the lung and causes pneumonia. Although achalasia can occur at all ages, it is most commonly diagnosed in patients between the ages of 20 and 60 years old.

Patients with disabling forms of achalasia who have not found lasting treatment through medications, botulism toxin injections, or balloon dilatation may be helped by surgery. Minimally invasive surgical techniques available at medical centers that specialize in esophageal surgery make this option more effective and easily tolerated than in the past.

Mayo Clinic is major referral center for achalasia treatment. Although the disorder is rare, thoracic surgeons at Mayo Clinic in Rochester have performed more than 250 surgical procedures to relieve severe achalasia in the past 8 years. In more than 90% of cases, the patients' symptoms were greatly improved and results were durable.

Although the cause of achalasia is unknown, 2 pathologies are usually involved. The first is loss of normal peristaltic function. This results in inability of the esophagus to push food through its length. The second is a hypertensive lower esophageal sphincter that fails to relax, thus trapping food. The surgical solution for a hypertensive sphincter involves 5 small (<1 cm) incisions through the abdominal wall so the sphincter can be divided with scissors or cautery to disable the hypertensive muscle. A partial fundoplication may be performed to help minimize problems with reflux after surgery.

Both the patients' tolerance of the procedure and the results are excellent. Most patients can swallow on the night after surgery and go home the next day. Median length of hospital stay has been 2 nights. Patients resume normal activities in a week or two.

Benefits and Limitations of Minimally Invasive Surgery for Achalasia

• Reduced hospital stay
• Reduced postoperative pain
• Excellent functional outcome, equivalent to open approach
• For the surgeon, affords easy opportunity to add fundoplication

• May not be appropriate when an extended myotomy up to the aortic arch is indicated
• Not suitable in the presence of midthoracic pulsion diverticulum