Heller myotomy is a surgical procedure in which the muscles of the cardia 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.
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 or through the abdomen.
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 speeds 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 esophagus, 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 mucosal layer intact.
This procedure can also be performed robotically.
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
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 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, 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.
References
External links UpToDate Patient Information: Achalasia