Benign Esophageal Disease Program

Achalasia develops when a muscular valve at the bottom of the esophagus fails to relax properly. The valve, known medically as the lower esophageal sphincter, may block the passage of food and liquids. As a result, patients have trouble eating or even swallowing. BIDMC offers two treatments for achalasia.

Laparoscopic Heller Myotomy

Laparoscopic Heller Myotomy has long been the standard treatment for achalasia, offering long-term relief of symptoms. While the patient is under general anesthesia, the surgeon uses a laparoscope to make small incisions in the abdomen. Using miniature instruments, the surgeon makes cuts in the esophageal sphincter so that the muscle relaxes and opens up. The patient usually goes home the next day.

Per Oral Endoscopic Myotomy (POEM)

Per Oral Endoscopic Myotomy, or POEM, is a newer minimally invasive procedure that may be an option for some patients. Using a team approach, a surgeon and gastroenterologist collaborate in this procedure. While the patient is under general anesthesia, the physician inserts an endoscope down the patient’s throat to make a small slit in the esophagus. The physician makes tiny cuts in the sphincter (similar to a traditional myotomy), which weakens the muscle enough to enable it to open. After repairing the slit in the esophagus, the physician removes the endoscope. The patient usually goes home the next day.

Heartburn, also known as gastroesophageal reflux disease (GERD) is very common. Usually, symptoms are well treated with medication alone. Surgery may be suggested if medication does not completely control your symptoms.

The cause of GERD is unknown. However, the muscle at the bottom of your esophagus is important in preventing heartburn. For those with GERD, this muscle either is not strong enough or opens at the wrong time, allowing acid from your stomach to travel up into the esophagus. Surgery for GERD is directed at strengthening this muscle.

GERD is often associated with a hiatal hernia. To understand what a hiatal hernia is, it is important to understand the diaphragm.

The diaphragm is a large muscle that separates the chest cavity, where the heart and lungs reside, from the abdominal cavity, where the stomach, liver, and intestines are. There is an opening in the diaphragm, called the hiatus. The esophagus goes through this opening, and connects with the stomach.

For people with a hiatal hernia, the hiatus enlarges. This allows part of the stomach to slip though the hiatus into the chest cavity. In some cases, half or even the entire stomach has moved into the chest. The cause of a hiatal hernia is unknown. We do know, however, that hernias gradually get larger over time, and a large hernia takes years to develop.

A hiatal hernia may be associated with heartburn. Large hernias may also lead to other symptoms, such as trouble swallowing, discomfort after eating, bleeding, and difficulty breathing. Medications rarely help these symptoms, and surgery can play an important role.

Surgical Treatment for Heartburn

Surgery for heartburn involves three steps:

1. Fixing the hiatal hernia (if one is present).
2. Making the hiatus smaller.
3. Creating a fundoplication.

Fixing the hiatal hernia means that we gently bring the part of the stomach that is within the chest back below the diaphragm. After this is done, we then focus on the hiatus. We don't close the hiatus completely. But using stitches, we make the opening smaller so the stomach is less likely to slip through the hiatus.

A fundoplication is the last step of the operation. What this means is that a small part of your stomach (the "fundus") is passed behind your esophagus.

You can think of a fundoplication as working like a belt for a pair of pants that are too loose. In the case of heartburn, the muscle that normally prevents acid reflux is too loose. The fundoplication is used to make that muscle a bit "tighter," thus preventing heartburn.

A fundoplication does not make the stomach smaller, and is not an operation to help people lose weight. However, it is common for patients to notice that food sometimes goes down slowly following surgery. This is almost always temporary, and is usually from some swelling at the fundoplication.

As the swelling goes down, you should be able to eat normally. Usually we will recommend that patients be on a modified diet until the swelling subsides.

New Treatment May Ease Heartburn

In this blog shared on Patch.com, BIDMC cardiothoracic surgeon Michael Kent, MD, discusses a magnetic management system to treat GERD.