Laparoscopic Heller’s Cardiomyotomy for Achalasia Cardia

Definition

Achalasia cardia is a rare primary esophageal motility disorder characterized by difficulty of passing of food and liquid contents into the stomach. It results from damage to the oesophageal nerves rendering it ineffective in muscular wall contraction with response to swallowing or passage of a food bolus. It is also called cardiospasm because of the severe spasm of the circular muscle of the lower end of the esophagus. The contracted segment does not relax during swallowing and this prevents the esophagus from squeezing food into the stomach at the gastroesophageal junction with consequent dilatation of, tortuosity for distal esophagus and abrupt narrowing at the junction.¹

Causes

• Damage to oesophageal nerves

• Abnormal response to the immune system

Types of Achalasia

•Type I - characterized by incomplete relaxation of the lower oesophageal sphincter

• Type II – a bit more severe than Type I exhibiting massive compression in the food pipe.³

• Type III – the most severe with chest pains that mirror a heart attack ¹

Symptoms of Achalasia Cardia

• Difficulty in swallowing

• Backflow of food into the throat (Regurgitation)

• Weight loss

• Chest pains

• Heartburn

• Discomfort after eating

Diagnosis/ Work up

• X-ray Chest- This shows dilatation of esophagus as a shadow behind the heart. Presence of a slight gastric bubble may be observed rarely.

• Barium swallow- This imaging study is done by asking patient to drink a contrast solution which will help visualize the esophagus. Barium swallow shows dilated esophagus, bird beak appearance due to narrowing of distal esophagus.

• Endoscopy- The entire esophagus and stomach is visualized through a camera chip attached to a scope as it goes down the oral cavity till the stomach. This test is more indicated if cancerous condition arises as a possibility. Biopsy samples are also removed during this procedure for malignant suspects.

• Manometry of esophagus- This test detects amount of pressure in the lower esophageal sphincter which is high; incomplete relaxation of LES is observed in achalasia cardia with absence of esophageal peristalsis in studies confirming the diagnosis.²

Barium swallow showing tortuous dilated esophagus with distal narrowing (beak sign) typical of Achalasia Cardia.

Treatment

Surgical care

Laparoscopic Heller’s cardiomyotomy involves cutting of the lower muscles of the esophageal sphincter to allow food to pass more easily into the stomach. Patients who undergo Heller’s cardiomyotomy may later develop gastroesophageal reflux disease (GERD) and that is why fundoplication is highly recommended at the same time with the procedure.⁴ The surgeon wraps the fundus of the stomach around the lower esophageal sphincter to tighten the muscle and prevent acid reflux.⁴ 

Laparoscopic Heller’s Cardiomyotomy with a Dor fundoplication of a young gentleman at Gendon Medical Centre at Upper Hill Medical Centre (UHMC)

Endoscopic Treatment

The per-oral endoscopic myotomy, or POEM, is a minimally invasive surgical procedure for the treatment of achalasia wherein the inner circular muscle layer of the lower esophageal sphincter is divided through a submucosal tunnel. The tunnel is created, and the myotomy performed, using a flexible endoscope, meaning the entire procedure can be done without external incisions. The major long term risk after POEM is new or worsened gastroesophageal reflux disease, which arises in 20-46% of patients. This phenomenon is usually mild and manageable with medication alone, and does not occur at a significantly higher rate than in patients undergoing a traditional surgical therapy. Incomplete myotomy resulting in a persistence of symptoms is also described and requires repeating the procedure. Other major complications are rare after POEM and include esophageal perforation and bleeding. Escape of air introduced through the endoscope into the surrounding tissues is a common occurrence and rarely requires additional intervention.³

References

1. https://reference.medscape.com/article/169974-overview

2. https://www.welcomecure.com/diseases/achalasia-cardia/tests-and-diagnosis

3. https://en.wikipedia.org/wiki/Per-oral_endoscopic_myotomy

4. https://www.mayoclinic.org/diseases-conditions/achalasia/diagnosis-treatment/drc-20352851