Surgery for Achalasia in Adults

NYU Langone gastroenterologists may recommend surgery to treat people with severe symptoms of achalasia, a neuromuscular condition that makes swallowing difficult. Some procedures may be performed using minimally invasive techniques. All require general anesthesia.

Heller Myotomy

NYU Langone surgeons use a minimally invasive procedure, called a laparoscopic Heller myotomy, to widen the lower esophageal sphincter—the muscular valve in the esophagus that allows food to pass into the stomach. Most people who can tolerate general anesthesia are good candidates for this procedure, including those who have already had upper abdominal surgery. 

During this procedure, the surgeon makes four or five small incisions in the upper portion of the abdomen. He or she inserts tiny instruments and a long, flexible tube with a camera at the end, called a laparoscope, into the abdomen. 

With guidance from the laparoscope, the surgeon separates the stomach and esophagus from the surrounding tissues. The surgeon cuts into the top layer of the lower part of the esophagus and upper part of the stomach to loosen them.

Although complications of this procedure are rare, some people may develop a perforation in the lower esophageal sphincter. If this occurs, it usually heals on its own while you are in the hospital. 

After a Heller myotomy, most people are able to return home within one to two days. You may have a swallowing study called a barium esophagram while you’re in the hospital to ensure the esophagus isn’t leaking. 

Your doctor may recommend sticking to a liquid diet for a week, then slowly incorporating soft foods into your diet. Most people experience relief almost immediately after surgery, and studies show that the majority continue to have symptom relief a decade later.

Fundoplication

Many people develop gastroesophageal reflux disease, or GERD, after a Heller myotomy. Because the procedure loosens the lower esophageal sphincter, it may allow stomach acid to travel backward into the esophagus. For this reason, the surgeon may recommend an additional procedure, called a fundoplication, during the Heller myotomy to prevent GERD symptoms.

During a fundoplication, the surgeon wraps the upper part of the stomach, called the fundus, around the bottom of the esophagus to strengthen the valve and prevent stomach acid from flowing back into the esophagus.

Peroral Endoscopic Myotomy

Peroral endoscopic myotomy, also called POEM, is the newest and least invasive surgical approach for severe achalasia. It may also be the most effective procedure for loosening the lower esophageal sphincter and improving swallowing. Researchers at NYU Langone continue to study the effectiveness of this promising technique.

During this procedure, the gastroenterologist or surgeon guides an endoscope—a thin, flexible tube with a camera at the end—through the mouth and into the esophagus. This allows the doctor to view the procedure on a computer monitor in the operating room. The endoscope is attached to a tiny scalpel, which is used to perform the procedure. 

First, the physician makes an incision in the lining of the esophagus. Next, he or she creates a tunnel between the lining of the esophagus and the muscle layer. Then the muscle is cut above, on, and below the lower esophageal sphincter in a manner very similar to a Heller myotomy. Once the myotomy is completed, the doctor closes the internal incision and removes the endoscope. The procedure can take up to three hours to complete.

Most people remain in the hospital for one day. The most common potential side effect of the procedure is GERD. If necessary, a fundoplication may be performed later. Your doctor may prescribe medication for any discomfort.

Esophagectomy

Esophagectomy involves removing the lower portion of the esophagus and reconstructing it with a portion of the stomach or colon. This is a major operation that rarely needs to be performed. It is only recommended for people with end-stage achalasia—or an almost complete inability to eat—whose symptoms do not respond to other treatments. 

Doctors at NYU Langone perform this procedure using open surgery, which requires incisions in the abdomen and chest, or with a laparoscope, which is inserted through an incision in the abdomen. 

After the surgeon has reconstructed the esophagus, a feeding tube, called a jejunostomy tube, is inserted into the small intestine to provide nutrition. When your doctor determines that you can begin to eat again, he or she removes the tube during an office visit. Most people can eat three or four days after surgery. Those with more severe achalasia may require a feeding tube for six to eight weeks.  

An open esophagectomy calls for a hospital stay of one to two weeks. People who have a laparoscopic procedure may return home sooner, usually after four to six days. 

You may have a temporary tube, called a catheter, inserted into the side of your chest to help drain fluids. It is removed before you return home. 

To avoid complications, the NYU Langone hospital staff assists you with breathing exercises. You may also receive medication to prevent blood clots. Our pain management specialists are available 24 hours a day to help you remain comfortable. 

After leaving the hospital, many people may need to eat soft foods and remain upright one to three hours after eating for several weeks. Full recovery can take up to six months.

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