This leaflet is intended for patients with achalasia considering a Laparoscopic Heller’s Myotomy.
What is achalasia?
Achalasia (a-kal-asia) is a disease of the oesophagus (food pipe or gullet) that makes swallowing difficult. Achalasia does not affect any other part of the body.
What causes achalasia?
The exact cause of achalasia is unclear.
Achalasia affects the nerves and muscles of the oesophagus. This causes two problems.
- The muscles of the oesophagus become ineffective at pushing food down towards the stomach
- The ring of muscle at the bottom of the oesophagus (called the lower oesophageal sphincter) fails to open to allow food past
How common is it?
Achalasia is rare. 1 person per 100,000 of the UK population is diagnosed with achalasia each year. It affects men and women equally. It is mostly diagnosed in people between the ages of 30 and 60 years.
What are the symptoms?
The most common symptom of achalasia is difficulty swallowing (dysphagia). This can occur with food and fluids. Food may feel stuck in the oesophagus causing chest discomfort, heart burn and weight loss over time. Regurgitation of food (bringing food back up) may happen as food cannot pass into the stomach and has nowhere to go but upwards. This can lead to choking, coughing and chest infections.
How is achalasia diagnosed?
As the symptoms are non-specific and achalasia is rare, there may be a delay in making a diagnosis. If doctors suspect achalasia, they will organise a number of tests:
- Gastroscopy (OGD) is an internal examination of the oesophagus, stomach and duodenum using a long flexible tube containing a camera. The tube is passed through the mouth into the oesophagus and stomach. This is a day case procedure under local anaesthetic or sedation.
- High Resolution Manometry is a test to measure the pressure in the oesophagus and lower oesophageal sphincter. The test is performed by passing a small tube through the nose into oesophagus.
- Barium Swallow involves drinking a liquid called barium whilst being X-rayed. This allows us to see what happens to your oesophagus when you swallow.
What treatments are available?
Patients may be offered one of the following treatments. Please note that all of these procedures aim to relieve symptoms of dysphagia but none can cure achalasia.
- Pneumatic Dilatation
The lower oesophagus is stretched using a balloon. This disrupts the muscle fibres of the lower oesophageal sphincter to ease the passage of food from the oesophagus to the stomach.
This procedure is done in the endoscopy or radiology department under sedation.
Patients are usually discharged the same day and advised to stay on a sloppy diet for 2 weeks, and then build up to a normal diet over 6 weeks. All patients are started on a high dose anti-acid medication for 2 weeks after the procedure. It is usual to be seen in the outpatient department 6 weeks after the procedure and then every 6 months to check that swallowing is satisfactory.
Pneumatic dilatation often needs to be performed several times to be effective.
Pneumatic dilatation carries a risk of puncturing the oesophagus (perforation). This is rare (5%). If the oesophagus is perforated this may require emergency surgery and / or a prolonged hospital stay to fix. People who have had pneumatic dilatation are more likely to suffer from heartburn after the procedure.
- Botulinum toxin (Botox) injection
This is performed using a gastroscope. Results are temporary (3 to 6 months only).
- Peroral Endoscopic Myotomy – POEM
This is performed in specialist centres. It is performed in the endoscopy department under a general anaesthetic. A hole is made in the lining of the oesophagus through which the muscles are cut. POEM increases the risk of reflux and heartburn. This is a relatively new technique with limited data on long term results.
- Laparoscopic Heller’s Cardiomyotomy
This is an operation performed under general anaesthetic via keyhole surgery. It involves cutting the muscles of the lower oesophageal sphincter to ease the passage of food from the oesophagus to the stomach. The success rate is 90%.
Do I need to fast before surgery?
Yes.
We recommend that you stop eating solid food and stick to a liquid diet 3 days before your surgery.
In the last 24 hours, you should stick to clear fluids only.
You should not eat or drink anything in the last 6 hours before the operation
The fasting instructions for achalasia surgery are different from other operations. This is because in achalasia the oesophagus clears very slowly, and there will still be food within it 6 hours after a meal. Clearing the oesophagus before surgery is very important as it reduces your risks of serious lung infection after surgery.
What can I expect on the day of surgery?
You will receive a letter with instructions about the date and place of your surgery.
When you arrive to the pre-op area, you will be admitted by the nursing team.
The surgeon will go through the risks and benefits of surgery with you and answer any questions you have before you sign the consent form. You have the right to withdraw consent at any time.
Risks, complications as well as alternative treatments will have been explained to you in detail in clinic before, so the consent process on the day is more of a recap and a chance to ask any additional questions you and your family may have thought of after the clinic consultation.
The anaesthetic doctor will go through risks of anaesthesia and talk you through the process of going to sleep and what to expect when you wake up.
What are the risks and complications from a Heller’s myotomy surgery?
- Bleeding
- Injury to a structure inside the abdomen or chest including the oesophagus, the vagus nerve, stomach, liver, spleen, lining of the lung and bowel
- Oesophageal leak – during the operation it is possible to make a hole in the oesophagus. We routinely look for this during surgery in the form of a leak test. If a hole is found it is repaired immediately. Occasionally a hole can present after the surgery. This is a serious complication which can lead to further surgery, a prolonged hospital stay, admission to intensive care, invasive lines and drains.
- Conversion from keyhole to open surgery
- Drain insertion
- Infection including that of the lung, blood, abdomen and urine
- Blood clots on the legs (deep vein thrombosis) and lungs (pulmonary embolism)
- Death – any surgery or invasive procedure carries a risk of death. The risk from a Heller’s myotomy varies from 1:1000 to 1:100 depending on an individual’s health.
What are the long-term complications of a Heller’s myotomy surgery?
- Reflux. By disrupting the lower oesophageal sphincter to ease swallowing, the surgery disrupts the anti-reflux mechanism of the oesophagus. Your surgeon may perform an anti-reflux procedure to reduce this risk of this happening.
- Recurrence of symptoms. Achalasia is a progressive condition which affects the whole oesophagus and can progress in time, requiring further treatment.
I heard surgery might be done with a robot, what is the difference?
Your operation may be performed using a surgical robot. This means that surgical instruments (normally held by a surgeon) will be held by a robotic device. Your surgeon will control the movement of these instruments from a console or computer next to the operating table.
Your operation will still be performed with keyhole surgery. This should not affect your recovery or the success of the operation. Your surgeon will tell you in advance if they plan to do your operation robotically.
What happens after surgery?
Once you can swallow fluids and your doctors are happy with your progress, you will be cleared to go home.
Can I eat normally after surgery?
After the operation you will need to follow a diet of puree then soft foods for a few weeks. Most people can resume a normal diet 6 weeks after surgery.
Your surgeon will tell you when you change from a puree to a soft diet. You will be given an Upper GI Surgery diet leaflet which contains more information and recipe ideas.
You must avoid fizzy drinks.
How long will you be in the hospital for a Heller’s Myotomy?
Length of stay following an uncomplicated Heller’s myotomy ranges from 1 to 2 days.
Upon discharge you will be given an Upper GI Surgery diet leaflet and a discharge summary. You will be given pain killers to keep you comfortable for the first few weeks. Please ask us for a fit note (Statement of Fitness for Work) if you need this for your work.
When can you resume normal activities?
You will be able to resume normal activities 6 to 8 weeks after surgery. Your oesophagus will need up to 6 months to heal.
When can I start to drive again?
Once you can sit in your car and use all the controls without discomfort. You must not be taking strong painkillers. You must be able to perform an emergency stop without pain. We usually recommend not driving for a week after keyhole surgery. It is always best to check with your insurance company to see if they have any specific rules related to the type of operation you have had done.
Will there be further follow up after the surgery?
An out-patient clinic appointment is usually made for approximately 6 weeks after surgery.
If you are experiencing any of the following symptoms, please contact your surgical team
- Unable to eat or drink.
- Severe pain
- Fever
- Feeling unwell
- Wound problems
Contact information
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If your operation was at |
Call: 07468 354 436 07826 921 319 |
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If your operation was at |
Call: |
If you cannot get in contact, please call 111 |
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If you feel seriously unwell, call 999 or go
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Please contact the patient advice and liaison service (PALS)
Frimley Park Hospital 0300 613 6530
Heatherwood Hospital and Wexham Park Hospital 0300 615 3365