Achalasia & Hiatal Hernia repair

Achalasia and other motility disorders of the oesophagus

Achalasia. Lower oesophagus sphincter fails to relax.

What is it?

These conditions are reasonably uncommon. It is best to start with how the esophagus works.

Most of the esophagus is controlled by involuntary means. That is we can't change the function of it. The way food is propelled into the esophagus is through a process called peristalsis. That means the muscle propels the food in a coordinated way into the stomach. These coordinated waves can be seen on a test called manometry. The esophagus also has a valve at it's lower end that opens to allow food through. This typically relaxes when the peristalsis is occurring and then closes as the food hits the stomach.

Achalasia is a condition that affects 1/100000 people therefore it is uncommon. In achalasia the waves that propel food into the stomach or peristalsis are absent therefore foods travels very slowly into the stomach. In addition to this the lower valve fails to relax and therefore there is a hold up of food at the lower end of the esophagus. This results in the sensation of food sticking or in medical terms dysphagia. Food may sit in the esophagus so long it is regurgitated when lying or even when standing.

Achalasia often starts with chest pain and reflux progressing to dysphagia. There are a range of conditions that may mimic achalasia or even be achalasia in it's early form. We call these motility disorders. The most common one is the nutcracker esophagus. This is the result of very high uncoordinated contractions along the esophagus. This results in chest pain and dysphagia. Some people believe this is a variant of achalasia and may continue onto achalasia later.

How do we diagnose achalasia

The gold standard is esophageal manometry. This a test where a fine tube is placed into the nose and then into the esophagus. It measures pressures in the esophagus with a series of swallows.

Barium swallow is also helpful.

Gastroscopy is of limited value but may show a pop as the scope goes through the tight valve. You may also see food in the esophagus.

Treatment

There are a number of ways to treat this condition.

Medical treatment includes stretching the valve with a gatroscope and balloon or injecting with botox. Both of these attempt to relax the valve but are not a permanent solution. They may make surgery harder in the future therefore you need to think carefully if considering this option.

Surgery is the best chance to fix this disorder. It is a keyhole operation called a Hellers myotomy. This involves cutting the lower valve allowing permanent relaxation. It is usually combined with a fundoplication to prevent reflux after cutting the valve. Although it is not perfect you should be able to eat solids and liquids easily.

Please remember that botox and balloon dilatation will make survey more difficult.

The treatment of nutcracker esophagus is more troublesome and generally is limited to medical management with a drug called nifedipine. Sometime ballon dilatation may help.

Hiatus Hernia

Hiatus hernia.

What is it?

Hiatus Hernia is a common condition that involves the part of the stomach in the chest rather than that in the abdomen. There are usually few symptoms but you may experience heartburn or, in more severe cases, pain and vomiting.

How is it treated?

Paraoesophageal hernias are a rarer type of hiatus hernia and generally need surgery. Sometimes these are called giant hiatal hernias. Most of these can be fixed using keyhole surgery.

It is important to realise that not all hiatus hernias cause problems. Before recommending treatment thorough investigation is needed prior to any surgery.

Large Hiatal Hernia

These hernias are relatively rare. Essentially the stomach and sometimes other organs such as the colon can slip through a large hole in the diaphragm. This means that they will be in the chest cavity rather than the abdominal cavity. The cause of this is largely unknown however a number of studies suggest that a collagen deficiency may be a factor. Also there has been good studies showing a condition called kyphosis or a hunched back is associated with this type of hernia.

What is the problem with these hernias?

There may be no problems however there are significant risks associated with these hernias. The stomach can twist in effect and cause sudden severe pain and vomiting. This is known as a volvulus. This can result in death of the stomach if left long enough and therefore needs urgent repair. The risk of this is about 1 percent per year therefore the younger you are the more likely you are to develop a volvulus and require emergency surgery.

Most people have more subtle symptoms which may include chest pain, shortness of breath, problems swallowing food and reflux or vomiting. Most of these hernias do cause symptoms and therefore should be repaired.

How do we repair them

This is a very specialised operation and should only be performed by surgeons with experience in advanced laparoscopic surgery and antireflux surgery. I have performed a large number of these repairs both in my training and in private practice.

The operation is performed keyhole although there is a much higher risk of open surgery than standard antireflux surgery. We reduce the stomach into the abdomen by dividing the attachments to the diaphragm this is also known as a sac. We then repair the diaphragm with stitches and mesh. This can be very difficult. A fundoplication is then performed and this is stitched to the diaphragm.

Sometimes an external drain is used. This attaches the stomach to the muscle and skin and stays in for 6 weeks. In my practice this is uncommon.

Even in the very best hands the recurrence rates for this operation are in the region of 20-30 percent. Although most recurrences are not prone to emergency volvulus.

What will I need prior to surgery

A barium swallow and gastroscopy at minimum. This allows me to map out the hernia and tailor my repair. Sometimes we will organize a CT scan with special reconstructions however old fashioned barium is usually as effective.

Rarely I wil organize a test of esophageal function called manometry.

What are the risks of surgery

• Damage to surrounding organs including the spleen and oesophagus
• Bleeding
• Collapse of the lung - may require a tube in the chest but rarely causes a problem
• In older people pneumonia and chest infection
• Conversion to open surgery
• Recurrence

More information

All of the information you need to know, pre and post-operatively, will be made available to you in separate information packs given to you before and after your surgery. Our practice nurse, Kylie, will also be able to assist you with any questions that you might have at any time.