Upper Gastrointestinal Surgery Unit

ESOPHAGEAL ACHALASIA

Esophageal achalasia is a motility disorder that results from the degeneration of nervous cells within the wall of the esophagus and esophago-gastric junction. Motility of both the esophageal body and lower sphincter is disturbed. Esophageal body contractions after deglutition are recorded as a non-propulsive motor activity so that ingested food reaches the stomach by gravitation only. In addition, the lower esophageal sphincter at the esophago-gastric junction fails to relax completely on deglutition so that ingested food accumulates in the esophagus. In end-stage disease, the esophagus becomes a large pouch that may take a sigmoid shape (Mega-esophagus).

Up to now, there is no therapy available to treat the motility disorder that affects the esophageal body so that the only treatment consists of the surgical division or the endoscopic disruption of the lower esophageal sphincter. As a consequence, the treatment aims to alleviate obstructive symptoms but cannot restore a normal esophageal motor function. This is why some symptoms may persist even after successful treatment.

Endoscopic dilatations are performed using an intraluminal balloon that is inflated once properly placed in the esophageal lumen.

Surgical division of the lower esophageal sphincter can be performed by either laparoscopy or a conventional abdominal incision (Heller myotomy). In order to prevent excessive reflux of gastric juice after the operation, an anterior fundoplication (Dor fundoplication) is performed at the end of the operation.

Data from the literature shows the superiority of the surgical myotomy over endoscopic balloon dilatations, especially in young patients. However, the latter treatment is indicated in elderly people who are at risk for a surgical operation.