What Is Oesophageal Achalasia in Children and how to treat it in Malaysia?
Oesophageal Achalasia is a rare condition that is mostly seen in adults but extremely rare in children. It is an oesophageal neurological disorder.
What is Oesophageal Achalasia?
The oesophagus is a muscular tube that extends from the back of the throat to the stomach, below the diaphragm. It has good muscular contractility and at the junction between the oesophagus and the stomach, it maintains a constant contraction until there is passage of food through it as it relaxes in a peristalsis movement. The muscle contraction here is important in preventing reflux of food from the stomach into the oesophagus normally.
In Achalasia the tone of this contraction is extremely high, making the opening here very tight and unable to relax to allow the smooth passage of food. Therefore, the oesophagus upstream to it becomes very dilated and stretched with swallowed food that is only very slowly passing through this narrowing.
Achalasia can occur at any age, most commonly at the ages of 20 to 40 years old and older. Why it happens, is not fully understood.
Symptoms of Oesophageal Achalasia
- Difficulties & Painful Swallowing
- Food Reflux – food that is stagnating in the oesophagus is pushed up into the mouth especially when lying down.
- Weight Loss – as progressively less food is entering the stomach to provide nutrition.
- Chest Pain – as food is accumulated on the upper end of the esophagus causing it to distend.
Surgical Treatment of Oesophageal Achalasia
The surgical procedure for the treatment of oesophageal achalasia is called Heller’s myotomy and a fundoplication is also done at the same time.
Essentially the muscle between “oesophagus and stomach is split longitudinally but leaving the inner lining, the mucosa, intact. The analogy is like the old bicycle tyres where there is the outer hard tyre (here the tight muscle) and the softer inner tube (here, the inner lining, the mucosa). By splitting the outer thick muscle, the inner lining will bulge out and open up the previously narrowed inner tube. Hence food can then pass easily down the oesophagus into the stomach.
However, this predisposes the patient to gastro-oesophageal reflux, hence the need to perform the fundoplication (another operation at the same time) to reduce that risk. This surgery gives the best permanent outcome, compared to other methods such as long term medications, stretching the area with a balloon or injecting the muscle with Botox, the latter two requiring endoscopy under anaesthesia to perform, all of which only gives some short term relief.
Less scarring, pain and faster recovery with Keyhole (Laparoscopic) Surgery
Laparoscopic surgery (or Keyhole Surgery) is far superior to traditional surgery for this procedure. For traditional surgery, a large cut needed to be made so that the surgeons hand can enter the wound to do the procedure inside.
In contrast, laparoscopic surgery requires only three tiny holes for the tiny instruments and camera to do the same.
In addition, the smaller incision causes less pain which shortens the post-operative hospitalisation and recovery time.
Dr Nada’s surgical intervention to save a young boy…
The condition of the little boy was very serious at that time, and he was malnourished. He could not swallow anything solids, only small amount of liquid was tolerated. With this he was also having aspiration of liquid feeds into his lungs and having multiple courses of antibiotics for lung infections.
Doctor Nada Sudhakaran, a specialist in paediatric laparoscopic surgery in Kuala Lumpur, completed a rare laparoscopic Heller’s surgery (with a fundoplication) for a child with oesophageal achalasia.
The surgery went very well and the little boy and his parents were overjoyed following the operation. He was able to eat normally. The stay after the surgery was for 2 only days and he has since been able to eat and grow normally.
Originally published in an article from Nanyang Siang Pau newspaper in 2014 in Malaysia.
