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Surgical treatment of achalasia

Achalasia is a condition of unknown aetiology resulting in difficulty propelling a food down the oesophagus into the stomach. This is due to impaired contraction of the muscles along the length of the oesophagus combined with increased pressure in the muscle at the very lower end of the oesophagus which fails to relax on swallowing.

Symptoms are typically difficulty swallowing and regurgitation of previously swallowed food and fluid back up the oesophagus. Patients are frequently initially thought to have gastro-oesophageal reflux. Endoscopic examination is frequently normal. A barium swallow (right) frequently shows the characteristic abnormality. The gold standard test is oesophageal manometry a specific test of muscle function performed in specialist centers.

Treatment cannot cure the condition but can only aim to improve oesophageal emptying by disrupting the muscle at the lower end of the oesophagus, the lower oesophageal sphincter. This can be achieved temporarily by the injection of botox. Long term treatment involves attempting to rupture the muscle by balloon dilatation, frequently requiring multiple procedures, or surgically dividing the muscle under direct vision which is routinely performed laparoscopically. Patients typically spend one night in hospital