ACHALASIA
Achalasia is a not very uncommon disease of the esophagus which causes increasing dysphagia (difficulty of swallowing). It is caused by hypertrophia (overgrowth) of the muscle in the distal (lower) part of the Esophagus making the passage of food to the stomach difficult- much the same as with congenital pyloric stenosis (see page PYLORIC STENOSIS) where the hypertrophied pyloric muscle blocks the passage to the duodenum.
It is important to differentiate this disease from cancer of the esophagus since it is easily corrected surgically. Contrary to cancer it is seen in young patients and when asked where the food gets stuck the patient will point at the distal part of the sternum. In advanced cases there might even be spill over of food to the lungs causing repeatedly pneumonias.
The diagnosis is confirmed with either esophago-gastroscopy or by a barium contrast X-ray which will show a typical “rat tail” narrowing of the distal esophagus.
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Treatment is very simple.
The distal part of the esophagus is isolated through a left thoracotomy incision in the 6’th or 7’th intercostal space
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The hypertrophied muscle is cut open in all its length….
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…and spread open with a hemostat until the mucosa bulges into the incision.
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This is called a myotomy (cutting the muscle) and is in principle the same procedure as used for treating congenital pyloric stenosis (see page PYLORIC STENOSIS)
The thoracotomy incision is closed with a chest tube inserted and connected to an underwater seal. The patient can start feeding immediately after the procedure and the chest tube can be removed as soon as the lung has expanded – usually after 24 hours.
The procedure can be done through an upper abdominal incision. I never tried that since it seems awkward and difficult to reach the upper part of the hypertrophied muscle.