Heller myotomy
Encyclopedia
Heller myotomy is a surgical
procedure in which the muscle
s of the cardia
(lower esophageal sphincter or LES) are cut, allowing food and liquids to pass to the stomach
. It is used to treat achalasia
, a disorder in which the lower esophageal sphincter
fails to relax properly, making it difficult for food and liquids to reach the stomach.
) or through the abdomen (laparotomy
). However, open procedures involve greater risks and longer recovery times . Modern Heller myotomy is normally performed using minimally invasive laparoscopic techniques, which minimize risks and speed recovery significantly.
, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact.
Food can easily pass downward after the myotomy has cut through the lower esophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial fundoplication to reduce the incidence of postoperative acid reflux. In Dor or anterior fundoplication, which is the most common method, part of the stomach (the fundus
) is laid over the front of the esophagus and stitched into place so that whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the esophagus instead. Nissen or complete fundoplication (wrapping the fundus all the way around the esophagus) is generally not considered advisable because peristalsis
is absent in achalasia patients.
This is a somewhat challenging operation, and surgeons have reported improved outcomes after their first 50 patients. An author search at Google Scholar can be used to find studies on a surgeon's past experience with achalasia patients.
After laparoscopic surgery, most patients can take clear liquids later the same day, start a soft diet
within 2–3 days, and return to a normal diet after one month. The typical hospital stay is 2–3 days, and many patients can return to work after two weeks. If the surgery is done open instead of laparoscopically, patients may need to take a month off work. Heavy lifting is typically restricted for six weeks or more.
The Heller myotomy is a long-term treatment, and many patients do not require any further treatment. However, some will eventually need pneumatic dilation
, repeat myotomy (usually performed as an open procedure the second time around), or esophagectomy
. It is important to monitor changes in the shape and function of the esophagus with an annual timed barium swallow
. Regular endoscopy
may also be useful to monitor changes in the tissue of the esophagus, since reflux may damage the esophagus over time, potentially causing the return of dysphagia
, or a premalignant condition
known as Barrett's esophagus
.
Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
procedure in which the muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
s of the cardia
Cardia
The cardia is the anatomical term for the part of the stomach attached to the esophagus. The cardia begins immediately distal to the z-line of the gastroesophageal junction, where the squamous epithelium of the esophagus gives way to the columnar epithelium of the gastrointestinal tract.Just...
(lower esophageal sphincter or LES) are cut, allowing food and liquids to pass to the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
. It is used to treat achalasia
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...
, a disorder in which the lower esophageal sphincter
Sphincter
A sphincter is an anatomical structure, or a circular muscle, that normally maintains constriction of a natural body passage or orifice and which relaxes as required by normal physiological functioning...
fails to relax properly, making it difficult for food and liquids to reach the stomach.
History and development
It was first performed by Ernest Heller in 1913. Then and until recently, this surgery was performed using an open procedure, either through the chest (thoracotomyThoracotomy
Thoracotomy is an incision into the pleural space of the chest. It is performed by a surgeon, and, rarely, by emergency physicians, to gain access to the thoracic organs, most commonly the heart, the lungs, the esophagus or thoracic aorta, or for access to the anterior spine such as is necessary...
) or through the abdomen (laparotomy
Laparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
). However, open procedures involve greater risks and longer recovery times . Modern Heller myotomy is normally performed using minimally invasive laparoscopic techniques, which minimize risks and speed recovery significantly.
Procedure
During the procedure, the patient is put under general anesthesia. Five or six small incisions are made in the abdominal wall and laparoscopic instruments are inserted. The myotomy is a lengthwise cut along the esophagusEsophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact.
Risks, complications, and outlook
There is a small risk of perforation during the myotomy. A gastrografin swallow is performed after the surgery to check for leaks. If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.Food can easily pass downward after the myotomy has cut through the lower esophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial fundoplication to reduce the incidence of postoperative acid reflux. In Dor or anterior fundoplication, which is the most common method, part of the stomach (the fundus
Fundus (stomach)
The fundus of the stomach is the left portion of the stomach's body, and is marked off from the remainder of the body by a plane passing horizontally through the cardiac orifice....
) is laid over the front of the esophagus and stitched into place so that whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the esophagus instead. Nissen or complete fundoplication (wrapping the fundus all the way around the esophagus) is generally not considered advisable because peristalsis
Peristalsis
Peristalsis is a radially symmetrical contraction and relaxation of muscles which propagates in a wave down the muscular tube, in an anterograde fashion. In humans, peristalsis is found in the contraction of smooth muscles to propel contents through the digestive tract. Earthworms use a similar...
is absent in achalasia patients.
This is a somewhat challenging operation, and surgeons have reported improved outcomes after their first 50 patients. An author search at Google Scholar can be used to find studies on a surgeon's past experience with achalasia patients.
After laparoscopic surgery, most patients can take clear liquids later the same day, start a soft diet
Soft diet
A soft diet is recommended in many situations, including some types of dysphagia , surgery involving the jaw, mouth or gastrointestinal tract, and pain from newly adjusted dental braces....
within 2–3 days, and return to a normal diet after one month. The typical hospital stay is 2–3 days, and many patients can return to work after two weeks. If the surgery is done open instead of laparoscopically, patients may need to take a month off work. Heavy lifting is typically restricted for six weeks or more.
The Heller myotomy is a long-term treatment, and many patients do not require any further treatment. However, some will eventually need pneumatic dilation
Esophageal dilatation
Esophageal dilatation is a therapeutic endoscopic procedure that enlarges the lumen of the esophagus.-Indications:It can be used to treat a number of medical conditions that result in narrowing of the esophageal lumen, or decrease motility in the distal esophagus...
, repeat myotomy (usually performed as an open procedure the second time around), or esophagectomy
Esophagectomy
Esophagectomy or Oesophagectomy is the surgical removal of all or part of the esophagus .-Purpose:...
. It is important to monitor changes in the shape and function of the esophagus with an annual timed barium swallow
Barium swallow
A barium swallow is a medical imaging procedure used to examine the upper GI tract, which includes the esophagus and, to a lesser extent, the stomach.-Principle:...
. Regular endoscopy
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
may also be useful to monitor changes in the tissue of the esophagus, since reflux may damage the esophagus over time, potentially causing the return of dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....
, or a premalignant condition
Premalignant condition
A precancerous condition is a disease, syndrome, or finding that, if left untreated, may lead to cancer. It is a generalized state associated with a significantly increased risk of cancer....
known as Barrett's esophagus
Barrett's esophagus
Barrett's esophagus refers to an abnormal change in the cells of the inferior portion of the esophagus. A positive diagnosis generally requires observing specific macroscopic and microscopic changes...
.
Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.