Heller's Cardiomyotomy + Fundoplication
Achalasia is a rare condition where there is failure of the lower gullet valve to relax with swallowing and the gullet contractions are uncoordinated, with failure of propagation of the food bolus to transit along the gullet. The patient will suffer from gradual onset of progressive dysphagia (difficulty with swallowing) to food and fluids. It usually takes years to develop and diagnosed late due to gradual onset. It could affect any age, from teenage to elderly patients. Laparoscopic Heller’s Cardiomyotomy is the recommended operation for this condition especially in fit and well patients, usually young ones. Alternatively to surgery, the gastroenterologist may offer endoscopic balloon dilatation, Botox injection or a combination of both. The latter approach is usually advisable for elderly unfit patients. It has less risk but needs to be repeated every 1-2 years.
Dysphagia (difficulty of swallowing) for both food and liquids is the main symptom which occurs gradually (over months - years), associated with weight loss, regurgitation (return of food and fluid back in to the throat and mouth), nausea and vomiting. Patients may also suffer from chest pain and spasms, heartburn, food stuck in the throat or behind the chest bone.
Clinically; symptoms and signs
CT scan, to exclude other causes of dysphagia
Endoscopy (camera examination of the gullet, stomach and duodenum) - OGD
May need 24hr pH monitoring
Conservative / Medical therapy: You may benefit from drinking fluids along with food in an upright position and avoiding
any food that you normally struggle with. This is a temporary solution.
Endoscopic therapy (usually avoided if surgical treatment is to be considered)
Botulinum toxin (Botox) injection: with minimal side effects compared to surgery but usually needs to be repeated every 6-12 months. Recommended for elderly frail patients.
Balloon dilatation: It has an increasing risk correlated directly with the numbers of dilatation. Usually safe for the first 1-2 attempts. It also may need to be repeated every 1-2 years. It is recommended for elderly frail patients and those unfit for surgery.
It is a keyhole surgery that involves 5 wounds, two of them around
2-3cm long and the other three are less than 1cm long - the figure
shows the sites of the wounds. There is a 3% chance of conversion
to open laparotomy (longitudinal cut) due to difficult operation, severe
adhesions or injury to surrounding structures that can’t be
resolved laparoscopically. This operation will include splitting (cutting)
the tight musculature of the lower oesophagus, the junction between
the gullet and stomach, with slight extension into the stomach,
preserving the lining of the gullet and stomach unbreached. Normally
the gullet and stomach will be assessed using the endoscope (camera test)
before and after the split to assess the difference and exclude any leak from
the undetected breach to the lining. Subsequently, a partial anterior (front)
wrap will be conducted to provide anti-reflux measure to minimise any
reflux symptoms after surgery. The operation usually takes an average of
3 hours to complete. A drain (tube) will be left on the left side of
the abdomen. There will be a tube (NG) left through one of the nostrils
into the stomach to decompress the stomach.
Both tubes will be removed around 48hr after surgery. All the wounds will
be closed with dissolvable stitches and covered with special glue.
Infection, bleeding, visceral injuries (injuries to surrounding organs), leak from the split site, chest drain (tube inserted into the left and/or right chest if there is breach into chest lining), dysphagia (usually transient), adhesions, hernia, chest infection, cardiac event and venous clot in the leg (DVT), which might migrate to lung (PE). There is a risk of bloating and loose motion which is related to rapid transit of food through the stomach that should settle with time and very unlikely to be longterm. Early recurrence of achalasia symptoms is uncommon if adequate myotomy performed in a true achalasia, but may occur after a long period of time. Persistence of dysphagia symptoms occur in 5-10% of patients depends on the type of achalasia and gut motility as well as on the surgical technique.
You will have a general ache with backache and shoulder pain due to filling the abdomen with gas that takes 48-72hr to be absorbed. It is advisable to have your pain killers regularly for the first 5 days then tail them off.
There are no stitches to be removed, you will have glue over the wounds. You could have a shower once the abdominal drain is removed but no bath until day 5 when you can rub the glue off in the bath/shower.
You will normally have an element of dysphagia (difficulty swallowing) that usually takes up to 6 weeks to settle. You usually stay in hospital for average of 3 nights. During your hospital stay, you will be progressed gradually in the oral intake until all the tubes/drains are removed. You will be discharged from hospital after tolerating soft diet.
Before discharge from hospital you need to meet 5 conditions:
• Feeling well and mobilising
• Tolerating soft food and drinking without being sick (vomiting)
• Normal observation (pulse, blood pressure and temperature)
• Passing urine normally
• Someone will stay with you overnight
You should continue on soft diet (avoid any solids), anti-acids and anti-sickness for 4-6 weeks until reviewed You should also avoid fizzy drinks for 6 months. All medications taken should be in a liquid or crushed form.
We can give you a sick note for 2-3 weeks and if you need an extra week, your doctor (GP) can provide you with this. You can walk, but be careful with stairs, always protect your larger wounds when coughing, sneezing or straining. You should avoid driving the first 10 days, and after that if you are able to control your vehicle and press emergency brake, then you can drive. Gradually increase activity back to normal over the next three weeks from surgery. Ideally, you should avoid flights, especially long distance, in the first four weeks after surgery and better to check with your flight insurer before booking.
I will review you in the clinic around 4 weeks following the surgery to assess your recovery where you will be progressed to normal diet gradually over next 2 weeks. You need to be careful on the methodology of eating: small bites, chew the food very well, make sure the food is moist (add lot of sauces), take your time with your meals (slowed pace) and eat little and often. if you have any problems you could contact my secretary or the hospital ward and I will be in touch.