Can you give me more information on myotomy? I was diagnosed with achalasia 15 years ago, and have had six attempts at dilation of the esophagus. A year ago, I also had botulism injection, which did not help. I'm wondering what my options are at this point.

B.

Achalasia is a condition of unknown cause in which the muscle of the esophagus loses its ability to function properly. The esophagus is unable to move food down into the stomach with the contractions, as normally occurs. Additionally, the lower esophageal sphincter, which separates the esophagus from the stomach, is excessively tight and will not adequately relax. These abnormalities lead to a large, dilated esophagus that tends to accumulate food debris. The food eventually passes into the stomach by virtue of gravity, after enough has accumulated in the esophagus.

This disease typically progresses over many years. Patients complain of difficulty swallowing, with a sensation that food is stuck in the esophagus. This may be accompanied by chest pain and regurgitation of food. The diagnosis is suggested by a patient's symptoms and confirmed by radiographic studies of the esophagus. The gold-standard test for achalasia is manometry, in which a probe is inserted into the esophagus (via the nose) to measure muscle pressures.

Treatment of achalasia centers on improving esophageal emptying by lowering the pressure in the lower esophageal sphincter. Therapies include medications, esophageal dilation, botulinum toxin injection and surgery (called myotomy).

Medications used in achalasia include nitrates and calcium-channel blockers, which act by directly relaxing the lower esophageal sphincter. They bring short-term relief to 50 to 70 percent of patients, but they are limited by side effects such as headache and low blood pressure. Their long-term effectiveness is unknown.

Esophageal dilation involves placing a balloon catheter into the esophagus and forcefully inflating the balloon within the lower esophageal sphincter. The result is a controlled tear in the sphincter muscle, which enables it to relax and allow food to pass into the stomach. Dilation is effective in 60-90 percent of patients in the short term, and in more than 60 percent at five years after treatment. The advantage of dilation is that it can be repeated if symptoms return, although the chance of success will be lower. The principal disadvantage is that it carries a 5 percent risk of esophageal perforation, which often requires emergency surgery to repair.

Botulinum toxin is a new therapy for achalasia. It is injected into the lower esophageal sphincter using an endoscope, and causes a controlled local relaxation. It is effective in 90 percent of patients, but the effect wears off after several months. Approximately 50 percent of patients will require another treatment within a year. The main side effect is chest pain after injection.

The most definitive therapy for achalasia is a surgical myotomy. This involves a controlled incision into the muscle of the lower esophageal sphincter to cause it to relax. Myotomy has the most lasting response rates, with effectiveness in more than 90 percent of patients in the short term and up to 75 percent after many years of follow-up. The main side effect is acid reflux (in 10 percent of patients), which occurs when the reduced pressure in the sphincter allows stomach acid to back up into the esophagus. Myotomy is now performed using a minimally invasive endoscopic approach. The death rate is less than 1 percent when this procedure is performed by expert surgeons.

In your case, after six dilations and an unsuccessful injection of botulinum toxin, the chance for success with further dilation is low, and the risk of perforation is always present. You should discuss your options with your doctor. Keep in mind that good results with myotomy are possible only if it is done by a surgeon very experienced in this field.