Achalasia;-A patient’s story
Where to begin, or rather when did it begin, I now know that this problem had existed for years and I did not know. The real problems started in November 2010 when I had difficulty in swallowing so I went to the doctors to see what he could do.
After examination the comment was “don’t think this will respond to pills” which did not exactly reassure me. So what were the symptoms at the staart? Difficulty swallowing. Pain on swallowing. A feeling that there was something stuck in the throat. At times, copious saliva production. Rapid onset of a pallid complexion. Inability to belch. As the complaint worsened:
Nighttime vomiting - Increase in pain on swallowing. Fortunately my doctor had referred me to the ENT clinic at James Cook University Hospital (JCUH) and I duly attended for my first appointment there. The consultant had a look down the throat and thought that he could see some acid attack of the Oesophagus but decided, fortunately, that a barium swallow was essential. 3 weeks later I was subjected to a Barium swallow and could see on the screens in the x ray suite the liquid descended and ponding at the Lower Oesophageal Sphincter (LOS) followed by what I now know to be the classic bird’s beak path of food into the stomach via the LOS. The procedure is not in the slightest unpleasant and the marshmallows went down too quickly for the radiographers!!
A return visit to see a different consultant revealed that it was too low in the gastric scheme of things and that it was now down to the Gastric team to come up with the answers. They did however tell me that they suspected Achalasia but that this would need further tests to confirm. 3 weeks later came my first appointment with the Endoscopy department and Dr Helen Dallal who introduced me to Mr. Viswanath who was to be my surgeon.
She went through the Radiology report with me and informed me of the 2 possible courses of treatment.
The first was a balloon dilation of the LES. The second being a more serious operation with a longer recovery time but 1 that could be repeated if necessary in the future. Either way I would need further tests to confirm the prognosis. Mr Vishwanath advised me that he would normally perform the procedure via keyhole surgery but if this was not possible that he would have to use a conventional incision which would take a longer stay in hospital before being released 3 weeks late the first of the tests took place in the Endoscopy department and this measured the pressure generated in the Oesophagus.
The test involves a small plastic tube with pressure sensors at 50mm intervals being passed up the nose and down into the stomach, uncomfortable rather than painful. The output from the sensors is then displayed on a screen and the operator can see how strong the muscle contraction are and whether they fire in the correct sequence. The operator also managed to position a sensor in the middle of the LOS.
This showed I had a contraction pressure of 25 to 30 units and an LOS pressure of 300 units, a normal person would be registering 70 to 90 and 100 to 110 units respectively. Clearly there was no way food could get through the LOS easily. The next day was an endoscopic examination of the Oesophagus and upon advice I elected to be sedated. This revealed that there were no underlying adverse issues to complicate surgery.
However the recovery time was about 24 hours and there was no way I could drive; even reading was a strange sensation. By now things had deteriorated to a point where the head end of the bed had to be elevated by 8” to try and get the trapped food to remain down and I had to take a bucket to bed to catch the vomit. As it had not entered the stomach it was not digested so there was no aroma thankfully.
Following the results a further consultation with the team indicated a July slot for surgery had been arranged.
I returned from holiday in early June to find 2 letters waiting for me, the first was to inform me of a pre-surgery review the following day and an admission date of the following Sunday. At the review I was closely questioned on health and fitness, blood samples were taken and an ECG performed, all were OK.
The next week was a bit of a blur as I prepared for surgery.
At 2 pm the following Sunday I was admitted to Ward 6 and the preparations started. DVT socks were issued and a tube inserted up my nose again and the Oesophagus was thoroughly washed out, unpleasant but essential.
The following day I was told to thoroughly shower and get into the gown provided. And then the wait began until 12:00 when a porter came and took me down to theatre.
In the meantime the anaesthetist and his team, came round and made sure I was fully informed and various consent forms were signed. In the theatre I was introduced to “Stan the Gas Man” who had to monitor me. A cannula was inserted into the back of my left hand and out I went. 5 hours later I woke up and then was taken back to the ward to recover.
I had a drip in the left hand and periodically I was given Paracetamol via the drip. Through the night my blood pressure, heart rate and temperature were taken.
At 4:00 am I was asked if I needed a bottle and said no I did not need to “go”. I was politely informed that if I did not start to urinate I would have a catheter inserted, believe me this is a very persuasive incentive. Needless to say I went copiously after that. Mr. Vish came to see me the following day and was pleased with my progress.
He advised me of the actions I should be taking when I left hospital.
4 weeks off work No driving for 2 weeks Lump free soup for 4 weeks followed by soft food for 4 weeks and then slowly introduce more solid food. No alcohol or fizzy drinks for 10 weeks. On the Wednesday morning a swallow test was performed to see if there were any leakage paths in the Oesophagus, fortunately there were none so I was allowed some ice cream and soup. Later that afternoon I was sent home with liquid Paracetamol for pain relief.
Recovery.
We bought a new liquidiser and we made soup and liquidised it thoroughly. Breakfast was well soaked Weetabix and fruit juice. We also made a lot of fruit smoothies and after a week, we made stews etc and liquidised them.Favourites were blue cheese and mushroom, chicken and sweet corn, split pea and a host of others.
BUT there was a price to pay. By liquidising the food the fibre was also chopped up very finely and as such made no contribution to stool formation. Constipation was extreme and I ended up taking Fybogel for several weeks before it settled down. So be warned it will happen!! After 2 weeks I drove for the first time after checking with my insurance company that I could, so again check for yourself, yours may have a different policy. At this stage my walking became much stronger and I would walk for a mile or so twice a day. Give gardening a miss especially hoeing and raking, it is not comfortable. After 4 weeks I went back to work and gradually over the course of 5 weeks returned to full time working.
At s weeks post op I started to introduce more solid food such as scrambled egg, well soaked muesli, stewed fruit, and a host of other soft foods. 10 weeks on and a normal diet was started, and alcohol was tried. The fizzy drinks caused a bit of a problem but gradually the stomach adapted to them and I have no problem since. As this was a time of experimentation some foods created problems:- Crisps, more than a couple and they seemed to jam and did not want to descend. Water solved the problem. Other things to be wary of;- Japanese rice crackers are like concrete Nuts can be awkward. Rice as in a rice salad is a no-no Pork can be awkward.
Chips are OK in small measures as is batter, but a standard fish supper has to be treated with care. Breadcrumbs are a problem. Apples can be difficult especially the harder varieties like Gala
I found that I must drink water or uncarbonated fruit juice with the meal, fizzy drinks cause problems.
Eat slowly and swallow small amounts. The sensation as the LOS opens is difficult to describe but is just like a rush of cold water into the stomach accompanied by relief. I have found eating at a table is the best position rather than from a tray in the lap watching the TV If you feel something jamming you will feel very uncomfortable and will produce lots of saliva. Find a toilet and vomit, it may take a couple of explosions before you get rid of the offending object but you will feel much more comfortable.
Exercise.
Walking was not a problem after a couple of weeks albeit slowly and after 6 months I am back in the gym, it would have been earlier but 1 of the wounds had a problem and it was not until 6 months later that this was finally resolved. After 7 months 4 of the 5 incisions are barely discernible simply a slightly darker red that the surrounding skin.
The fifth in the navel has now fully healed and is steadily fading away. I have been back to the hospital 3 times for a check up and I will be summoned for another endoscopic examination later this year.
Would I rate it as a success?
Absolutely it has improved my quality of life dramatically and I can now eat almost normally.The standard of care I received at James Cook could not be faulted, the nurses on the ward had that typically British manner of mixing utter professionalism with banter and gentle verbal abuse that is typical of the camaraderie of the workplace and which leads to a more rapid recovery.
Would I recommend it to you? Most definitely and that is why I have penned this brief missive for Mr. Vish and the Endoscopy department to use as a reference for any patients who present with the same symptoms. If you have any other queries I would be prepared to talk to you and you should ask the team for my details.
After Complex Groin and Spigelian hernia repair
Additional Information
JS Says...
"Dear Mr Viswanath,
In November 2011 and having had an ultrasonic scan, you diagnosed me as having a very large abdominal rupture and double hernia. My intestines were protruding through the lower abdominal muscle wall. Both hernias were located on my right side in my groin area with one entering my scrotum immediately above my right testicle and the remaining one in my right pushing towards the inguinal canal. The only way to deal with hernia’s of this type and magnitude is to undergo surgery, which you professionally carried out on the 8th December 2011 at The Woodlands Hospital in Darlington County Durham. On Friday 2nd December 2011, one week before the operation, whilst in Lincolnshire and without warning, my hernia slipped out and located itself in my inguinal canal, this situation and development had been a common occurrence during November, therefore, providing I laid horizontal upon experiencing this uncomfortable predicament, I was able to apply pressure from my hand palm and push the hernia back in place. Unfortunately on this occasion I could not push it back in position through my abdominal wall.
Both the pain and pressure in my groin area was severe and eventually I ended up in Grimsby General Hospital where I was admitted, with the intention of having emergency overnight surgery for what the Hospital Staff diagnosed as a possible strangulated hernia. Fortunately, the hernia settled down and was pushed back in position by A&E doctors. The following day, I was discharged and allowed home with the intent of having surgery on 8th December 2011. During what turned out to be reasonably complicated surgery, you mentioned that not only did you discover the large abdominal rupture and double hernias, but you discovered a large benign abdominal fat lump that you decided to completely remove.
The whole operation was described as being quite rare and very interesting. In January 2009, I was having trouble with my bladder resulting in me having the constant sensation of wanting to urinate every 30 minutes. This was diagnosed as a large prostrate resulting in surgery to have a “TURP” operation. Prostatic tissue was removed and so the physical bulk of my prostate was reduced. This operation helped improve my urine flow, however, the sensation of having a full bladder did not fully disappear. Since you performed the perfect and successful operation with respect to the hernias, my bladder has also taken an astonishing and vast improvement with respect to the “being full” sensation. This annoying symptom has completely disappeared. Perhaps, because you chose to remove the large fat lump, this has reduced the internal pressure on my bladder.
Special thanks to The Woodlands Hospital, your team and of course yourself for all the superb and prompt/professional attention and care you gave me, throughout November and December. Without question, you have improved my lifestyle quality in many ways. I would like you to publish this letter in the hope that it will help and give anyone experiencing similar symptoms additional confidence and comfort that they will be in very capable and knowledgeable hands."
After hernia surgery 2021
