Minimally Invasive Robotic and Laparoscopic Heller Myotomy (Achalasia)

Achalasia is a rare disorder of the esophagus (the tube that carries food from the mouth to the stomach) that makes it difficult for food and liquid to pass into the stomach. In achalasia, the esophagus loses its ability to push food down and the muscular valve between the esophagus and the stomach (the lower esophageal sphincter) doesn’t fully relax. This condition is caused by damage to the nerves in the esophagus. Achalasia is a rare disorder. It may occur at any age, but is most common in middle-aged or older adults. This problem may be inherited in some people.

In many patients, the onset of achalasia symptoms can be gradual. In others, symptoms occur and progress much more rapidly. Common symptoms include:

• Backflow (regurgitation) of food
• Chest pain, which may increase after eating
• Difficulty swallowing liquids and solids
• Heartburn
• Unintentional weight loss

There are a variety of tests needed to confirm the diagnosis of achalasia, and to rule out other possible problems. These tests include:

• Upper endoscopy: in this procedure a thin, flexible fiberoptic scope is gently guided down the esophagus and into the stomach. During this procedure, patients are sedated. Upper endoscopy is necessary to examine the esophagus.
  
  
• Upper GI x-ray: for this test, a little bit of x-ray contrast dye is swallowed.
  
  
• Esophageal manometry: this test involves the placement of a soft, thin tube through the nose and into the esophagus. Patients are asked to swallow and the motility of the esophagus (squeeze pressure and pattern) is measured.

In some patients, additional testing is necessary.

The approach to treatment is to reduce the pressure at the lower esophageal sphincter and to help the esophagus empty better. Treatment may involve:

• Botulinum toxin (Botox): This can be injected into the lower esophageal sphincter and may help relax the sphincter muscles, but any benefit wears off within a matter of weeks or months. Botox is also thought to make any future surgical procedure for achalasia more difficult.
  
  
• Medications: Certain medications such as long-acting nitrates or calcium channel blockers can be used to relax the lower esophagus sphincter.
  
  
• Endoscopic dilation: Widening (dilation) of the esophagus near the lower esophageal sphincter can be performed with an endoscope. This procedure is less likely to work in certain patients than in others. A gastroenterologist will usually help patients better understand the risks and options to endoscopic dilation, and can help determine if endoscopic dilation should be attempted.
  
  
• Surgery: The surgical procedure for achalasia is called an esophagomyotomy, also known as a Heller myotomy. This procedure is usually performed in a minimally invasive manner with small incisions (either laparoscopically or robotically). The goal in surgery is to cut all of the muscle fibers in the lower esophageal sphincter to allow the esophagus to empty better.
  
  
• POEM - Per-Oral Endoscopic Myotomy for Achalasia: Minimally Invasive Foregut Surgeons in the Division of General Surgery at the Medical College of Wisconsin are proud to offer a novel, scarless procedure that restores swallowing function in some patients with achalasia, a rare condition where the esophagus is unable to move food into the stomach. Per-oral endoscopic myotomy (POEM) is a state-of-the-art technique to treat patients who have achalasia. POEM is an incisionless procedure which utilizes endoscopy to perform a targeted myotomy of the circular muscle fibers of the lower esophagus. This allows food to pass more easily and helps patients eat more comfortably. Additionally, the POEM procedure is performed without any external incisions and as a result there are no surgical scars. The POEM procedure provides a more minimally invasive approach to achalasia that can help patients recover more quickly than a traditional surgical approach (Heller myotomy).

Achalasia is a rare disease (roughly 1 per 100,000 in the United States). Surgery for achalasia is difficult, and the results can be highly dependent on the experience and skills of the surgeon. It is essential that the muscle of the lower esophageal sphincter be divided completely (cutting the muscle of the sphincter is known as a myotomy), and that the myotomy extends down far enough onto the stomach to relieve the esophageal outflow obstruction. An incomplete myotomy or one that does not extend onto the stomach may cause swallowing problems to persist or recur after surgery.

It is best to perform surgery for achalasia in the earlier stages of disease. In some patients who have suffered from achalasia for many years, the esophagus becomes dilated and may also become ‘sigmoid shaped’ (looks like the letter ‘s’). The results of surgery may not be as good or as durable in patients with very advanced disease.

When the lower esophageal sphincter is cut to treat achalasia, patients are at increased risk for developing gastroesophageal reflux disease. In some patients, a partial fundoplication is added to the myotomy to decrease the chance that this will happen.

In both laparoscopic and robotic myotomy for achalasia, the procedure is performed under general anesthesia and 5-6 small (1-cm or less) incisions are made on the patient’s abdomen. The surgeon watches a video monitor that displays a view from the inside of the abdomen. Both laparoscopic and robotic myotomy take about 2-3 hours to complete, and patients are usually in the hospital for 1-2 days following surgery.

The surgical robot is a tool that has been shown to be valuable when performing esophagomyotomy for achalasia. During surgery, the robot projects a 3-dimensional, high definition image to the surgeon. This makes it easier to see all of the small esophageal muscle fibers near the lower esophageal sphincter. The robot is also capable of computer-enhanced movements that increase the accuracy and precision of the surgeon during the myotomy.

POEM is an incisionless procedure which utilizes endoscopy to perform a targeted myotomy of the circular muscle fibers of the lower esophagus and esophageal sphincter. This allows food to pass more easily and helps patients eat more comfortably. Additionally, the POEM procedure is performed without any external incisions and as a result there are no surgical scars. The POEM procedure provides a more minimally invasive approach to achalasia that can help patients recover more quickly than a traditional surgical approach (Heller myotomy). The POEM procedure is a relatively new technique, and not all patients with achalasia are appropriate for the POEM. If interested, schedule a visit with an MCW Minimally Invasive Foregut Surgeon to discuss the pros and cons of POEM and whether you are a candidate.

Minimally invasive foregut surgeons in the Division of General Surgery at the Medical College of Wisconsin are some of the most experienced achalasia surgeons in the Midwest. Achalasia can be mistaken for other digestive tract disorders. Our colleagues in the Division of Gastroenterology work collaboratively with us to make the right diagnosis and to help determine the best treatment option for an individual patient.