TürkçeAchalasia should initially be evaluated in the Gastroenterology or Internal Medicine outpatient clinics for diagnosis and treatment, while patients seeking a permanent surgical solution should be referred directly to Thoracic Surgery specialists. Restoring normal esophageal motility, eliminating swallowing difficulties, and improving the patient’s quality of life are possible through the professional expertise of surgeons experienced in thoracic procedures. When symptoms such as difficulty swallowing or chest pain occur, scheduling an appointment with the Thoracic Surgery department without delay is of vital importance for determining the most appropriate treatment strategy. This department aims to help patients regain healthy swallowing through modern surgical techniques that preserve anatomical structures, while specialist supervision ensures both an accurate diagnosis and long-term recovery.
Which Department Should You Visit for Suspected Achalasia and When Should You See a Thoracic Surgeon?
People who experience difficulty swallowing, feel that food becomes stuck in the chest, or develop unexplained weight loss naturally and appropriately seek medical attention as their first step. In such cases, the first outpatient clinics typically visited are Internal Medicine, Gastroenterology, or General Surgery. Specialists in these departments perform a detailed initial evaluation to determine the underlying cause of the patient’s symptoms.
Particularly when difficulty swallowing is present, physicians first aim to rule out more dangerous underlying conditions. They evaluate the possibility of an esophageal mass, external compression, or an inflammatory stricture. Once various imaging studies and diagnostic tests clarify that the problem is caused by failure of the lower esophageal sphincter to relax—that is, achalasia—the treatment planning phase begins.
At this stage, when a permanent structural solution is sought, the patient is referred to the Thoracic Surgery department. Restoring esophageal function, surgically relieving the persistently contracted muscle, and accomplishing this without damaging surrounding organs require highly specialized expertise. When medications or temporary interventions are insufficient, thoracic surgeons address the anatomical problem directly to provide lasting symptom relief.
Why Are Thoracic Surgeons Important in the Treatment of Achalasia?
One of the main factors determining which surgical specialty manages a particular organ is its anatomical location and neighboring structures. The esophagus begins in the neck, passes through the entire thoracic cavity from top to bottom, then crosses the diaphragm before connecting to the stomach within the abdominal cavity. Along this course, it remains in close proximity to the lungs, heart, aorta, and trachea.
The thoracic cavity is a closed and highly delicate space containing constantly moving vital organs. Thoracic surgeons possess comprehensive knowledge of the anatomy, dynamics, and potential risks associated with this region. Although achalasia procedures are generally performed laparoscopically through the abdomen, the area being treated lies immediately beneath the thoracic cavity. If even a minor complication develops within the thoracic portion of the esophagus or direct intervention within the chest becomes necessary, the expertise of thoracic surgeons ensures much safer management. Furthermore, distinguishing whether swallowing difficulty is caused by achalasia or by a malignant esophageal disease, and planning surgery according to oncological principles when necessary, also falls within the expertise of this specialty.
Which Methods Are Used to Diagnose Achalasia?
Physicians use several diagnostic tests to confirm the diagnosis and establish a surgical roadmap before treatment. These investigations help determine both the presence of the disease and its stage.
The main diagnostic tests include:
- Contrast barium swallow study
- Upper gastrointestinal endoscopy
- High-resolution esophageal manometry
A barium swallow study involves the patient drinking a chalky white liquid while X-ray images are taken to visualize its passage through the esophagus. In patients with achalasia, the body of the esophagus appears markedly dilated, while the lower end narrows into a thin channel. This characteristic appearance is commonly referred to as the “bird’s beak” sign.
During endoscopy, a flexible tube equipped with a light and camera is advanced through the esophagus into the stomach. The primary objective is to exclude tumors or other structural abnormalities that may cause swallowing difficulties. In patients with achalasia, retained food debris and a dilated esophageal lumen may be observed.
High-resolution manometry is considered the gold standard for diagnosis. A catheter equipped with multiple pressure sensors is inserted through the nose to measure esophageal muscle contractions. As the patient swallows, muscle activity and lower esophageal sphincter pressure are displayed on a computer screen as color-coded pressure maps. This test identifies disease subtypes and helps determine the appropriate length of muscle division during surgery.
What Is the Eckardt Scoring System Used to Measure Achalasia Severity?
When evaluating patients, physicians need objective numerical values to assess symptom severity. One of the most widely used tools for assessing achalasia is the Eckardt Score, which converts clinical symptoms into a measurable numerical value.
During evaluation, weight loss, frequency of swallowing difficulty, chest pain, and food regurgitation are scored. Each symptom receives a score ranging from 0 to 3 according to its severity. The total score reflects the extent to which the disease affects the patient’s quality of life. One of the primary treatment goals is to reduce this score following surgical intervention. Comparing preoperative and postoperative scores provides valuable insight into the effectiveness of treatment.
What Is Laparoscopic Heller Myotomy Performed by Thoracic Surgeons?
The most commonly preferred surgical treatment for opening the tightly closed lower esophageal sphincter in achalasia patients is known as Laparoscopic Heller Myotomy. Whereas this operation previously required large incisions in the chest or abdomen, advances in minimally invasive surgery now allow it to be performed with considerably less trauma.
The operation is carried out under general anesthesia. Instead of making large abdominal incisions, surgeons insert cameras and long, specialized instruments through several small openings. Carbon dioxide gas is used to inflate the abdominal cavity, creating a clear operative field. The surgeon performs the procedure while viewing the anatomy on high-definition monitors.
The primary objective of surgery is to divide the persistently contracted circular muscle layer longitudinally. Great care is taken to preserve the mucosal lining immediately beneath the muscle. The muscle division begins on the stomach and extends upward along the lower esophagus to relieve the obstruction.
However, muscle division alone is not considered sufficient treatment. Although swallowing improves significantly, cutting the sphincter leaves the stomach permanently open, increasing the risk of severe gastroesophageal reflux. To prevent this complication, surgeons wrap the upper portion of the stomach around the area of muscle division as a protective barrier (fundoplication). This additional procedure aims to restore normal swallowing while minimizing the likelihood of postoperative reflux.
In Which Situations Is Peroral Endoscopic Myotomy (POEM) Used for Achalasia?
With advances in medical technology, a technique known as Peroral Endoscopic Myotomy (POEM) has emerged for treating achalasia without making any external incisions. As its name suggests, this procedure is performed entirely through the mouth using an endoscope.
Under general anesthesia, the endoscope is advanced through the mouth into the lower esophagus. A small incision is made in the mucosal layer, allowing a tunnel to be created within the esophageal wall. The endoscope advances through this tunnel to reach the diseased circular muscle layer, which is then divided internally. Once the procedure is complete, the entry site is closed using specialized endoscopic clips.
This technique is particularly beneficial for patients with long segments of severe esophageal spasm, especially those with Type III achalasia identified by manometry, because it allows a longer myotomy. Although the absence of external scars is advantageous, POEM has one important limitation. Unlike laparoscopic surgery, an anti-reflux fundoplication cannot be performed. Consequently, postoperative reflux is more common, and patients often require long-term acid-suppressive medications.
Why May Esophagectomy Become Necessary in Advanced Achalasia?
When achalasia is not treated appropriately in a timely manner, patients develop not only nutritional problems but also irreversible structural changes within the esophagus. Over many years, accumulated food progressively stretches the esophageal wall. What was once a slender muscular tube gradually becomes enlarged, tortuous, and transformed into a massive pouch. This condition, known medically as megaesophagus, represents complete loss of esophageal function.
At this advanced stage, simply dividing the sphincter muscle is no longer sufficient because food remains trapped within the severely enlarged esophagus despite an open lower sphincter. Patients become increasingly susceptible to aspiration and severe pneumonia. In these end-stage cases, esophagectomy may become the final treatment option. During this major operation, the completely nonfunctional esophagus is surgically removed. The stomach is then reshaped into a tube, brought upward into the chest or neck, and connected to the remaining upper esophagus to restore digestive continuity. This demanding procedure is reserved for extremely advanced cases where life-threatening complications must be prevented.
What Are the Comparative Outcomes of Different Achalasia Treatments?
After diagnosis, patients may be offered temporary, intermediate, or long-lasting treatment options depending on their condition, age, and surgical risk. The principal treatment approaches include:
- Botulinum toxin injection
- Pneumatic balloon dilation
- Surgical or endoscopic myotomy
Botulinum toxin injection involves administering the medication, widely known from cosmetic applications, into the muscles of the lower esophagus using endoscopy. This temporarily paralyzes and relaxes the muscles, providing symptom relief for several months. However, its effects are short-lived and repeated treatments become necessary. Repeated injections also cause tissue fibrosis and adhesions, making future definitive surgery technically more difficult. Therefore, this approach is generally reserved for elderly patients who are poor surgical candidates.
Balloon dilation involves placing and inflating a balloon within the lower esophagus to forcibly tear the sphincter muscle. Because this is not a controlled incision, there is a risk of esophageal perforation. In addition, reflux symptoms occur relatively frequently following balloon dilation, and recurrence rates remain significant over time.
Surgical treatment with Laparoscopic Heller Myotomy provides the most reliable long-term outcomes because the sphincter muscles are divided under direct visualization, and an anti-reflux barrier is simultaneously created. Numerous scientific studies report higher long-term patient satisfaction with surgery compared with other treatment methods.
What Happens During Hospitalization After Achalasia Surgery?
Recovery following surgery is generally more comfortable than many patients expect because minimally invasive techniques are used. During the first postoperative day, intravenous fluids and nutritional support are typically provided while the body rests and the surgical area begins healing.
The following day, if approved by the surgeon, patients gradually begin consuming clear liquids. For many individuals, experiencing water pass effortlessly into the stomach without pain or obstruction after years of swallowing difficulty is an emotional and reassuring milestone. As recovery progresses, the diet is gradually advanced from liquids to soft foods. Patients who remain free of fever, severe pain, or other complications are usually discharged home within a few days after surgery.
Which Foods Should Be Avoided After Achalasia Surgery?
The first weeks after surgery represent a delicate healing period during which the tissues continue recovering internally. Although the anatomical obstruction has been corrected, the esophagus requires time to adapt to its new function. Therefore, patients are advised to consume soft, pureed, non-irritating foods during this period.
The main foods and beverages patients should avoid include:
- Carbonated beverages
- Strong brewed black tea
- Strong coffee
- All alcoholic beverages
- High-fat and fried foods
- Spicy foods
- Vinegar
- Highly acidic citrus juices
These dietary restrictions have well-established medical reasons. Carbonated beverages can rapidly distend the stomach and esophagus with gas, potentially stressing sutures and healing tissues. Tea, coffee, spicy foods, alcohol, and vinegar may stimulate gastric acid production, causing reflux symptoms while also irritating the healing esophageal lining, resulting in unnecessary pain and delayed recovery.
Frequently Asked Questions
Prof. Dr. Alper Fındıkcıoğlu graduated from Istanbul University Faculty of Medicine and completed his thoracic surgery residency at Dr. Siyami Ersek Hospital. He began his academic career at Başkent University in 2005; he received the title of associate professor in 2014 and professor in 2022. He has extensive experience in lung cancer, chest wall diseases, and minimally invasive surgery. Since 2024, he has been continuing his professional work at Acıbadem Hospital.
