Achalasia Surgery Frequently Asked Questions

Patients remain in the hospital for 4 to 6 days after the operation.  The primary reason is postoperative discomfort; patients who have less discomfort may be discharged on the second or third day after surgery.

After discharge, patients begin to resume normal activities except heavy lifting or driving. Patients should not drive  or make important decisions while taking narcotics.  Within 2 weeks, most patients can drive and by 4 to 6 weeks they can return to work and heavy lifting.

Rather than making a large incision and looking directly into the abdomen, laparoscopic surgery makes small incisions of 5 to 10 mm (1/5 to 2/5 inches) and uses a telescope to see the abdomen.  The scope is attached to a camera that allows surgeons to operate while watching on a television screen.  A laparoscopic myotomy requires two incisions of 5 mm (1/5 of inch) and three that are 10 mm (2/5 of inch).  Tubes are passed through these incisions to allow access into the abdomen. Surgery is performed using instruments passed through the small tubes.

Usually, the operation takes from one to two hours.  The longer operations usually result when an anti-reflux operation is combined with the myotomy.

Patients stay in the hospital overnight, so they can be monitored for rare complications such as bleeding or perforation.  Most patients go home the following day,  after they obtain an upper GI series, drink liquids and eat soft foods.

The major advantage of laparoscopic surgery over open conventional surgery is the significantly shorter recuperative period.  This derives from the smaller incisions used.  A few patients are able to perform normal activities the day they go home but most people require 2 to 3 days to return to normal.  In addition, although some patients return to work in 3 to 4 days, most return back 2 to 3 weeks after surgery.

The laparoscopic approach was introduced in the early 1990s based on the success observed with laparoscopic gallbladder removal.  Studies to date have shown less pain, earlier return to normal activities and earlier return to work for the laparoscopic approach.  It is important to recognize that everyone is different in regard to the perception of pain: One person may undergo an open Heller myotomy and return to work in a couple of weeks while another person undergoing a laparoscopic myotomy returns to work in 6 weeks.

The actual operation performed during a laparoscopic or open approach is the same; namely dividing the lower esophageal sphincter muscle.  The laparoscopic approach is preferable based on the earlier discharge after surgery, the shorter recovery time, and smaller scarring.  There appears to be no difference in complication rates between the two procedures.

Most patients requiring a myotomy can undergo the procedure laparoscopically.  Occasionally, it is not possible to complete the operation laparoscopically.  In this situation, the operation is converted to an open procedure.  Overall, more than 95 percent of patients can undergo a successful laparoscopic myotomy.

A variety of factors decrease the chance of the surgeon being able to complete the procedure laparoscopically.  These include: inflammation, previous surgery, unclear anatomy, previously unrecognized abnormalities, or an intraoperative problem such as bleeding or perforation.  Conversion of a laparoscopic procedure to an open one should not be viewed as a complication, since some patients simply are unable to have the surgery performed laparoscopically without undue risk.  The goal is to perform a safe and uncomplicated procedure, so no unnecessary risks will be taken merely to complete the procedure laparoscopically.

All surgeons perform the open approach but only some surgeons perform the laparoscopic approach.  Before surgery is scheduled, find out whether the surgeon performs one or both approaches and how many of each he or she has performed.

Complications are possible in all operations and esophageal myotomy is no different. Complications common to both open and laparoscopic myotomy are: 

• Bleeding. Fortunately, bleeding during or after this procedure is very uncommon. As a result, we do not routinely ask patients to donate their own blood prior to surgery. However, self (autologous) donation of blood can be arranged prior to the operation.
• Infection. Infection from esophageal myotomy can occur in the incision, in another organ such as the lungs or at the site of the myotomy. Infection at the incision and at another site are more common following open surgery than laparoscopic but still is quite unusual.
• Perforation. Infection at the site of the myotomy is usually related to a perforation of the inner lining of the esophagus. This may require an additional operation but often can be treated with antibiotics.

Other Complications

Late complications of myotomy include the development of a hernia at the site of an incision, a bowel obstruction or recurrence of the achalasia. The formation of a hernia and the later development of a bowel obstruction are both more common following an open myotomy than a laparoscopic one. Hernia is more common because the incision is larger. Bowel obstruction is more common because open surgery produces more scar tissue (adhesions) than laparoscopic surgery. Approximately 90 percent of patients have good to excellent results following surgery; it is maintained long term in 90 percent of these patients.

Laparoscopic surgery has rare complications related to the initiation of the laparoscopy itself. Approximately one in 1000 patients will have an injury to the intestine or a major blood vessel when we start the laparoscopy. If this should occur, the surgeon may need to convert the operation to an open one to correct the problem. 

This incidence can be reduced to almost zero by using a technique call open laparoscopy. In this technique a small incision is made into the abdomen under direct vision rather than placing a needle into the abdomen to start the laparoscopy. We always use the open technique and have not had a significant problem with it to date.