Open Heller Myotomy
- Author: Adriana Laser, MD, MPH; Chief Editor: Kurt E Roberts, MD more...
In 1913, Ernest Heller reported the first successful cardiomyotomy for achalasia. He used 8-cm parallel myotomies (anterior and posterior). These were considered extensive, and, in 1918, De Brune Groenveldt and Zaaijer described the single incision known today. This transabdominal approach remained the criterion standard in Europe until minimally invasive techniques superseded them more recently. However, in North America, the Heller myotomy approach of choice was via a left thoracotomy after being described in this way by Ellis et al in 1958. Traditionally, no associated antireflux procedure was performed. The transabdominal approach is now the most common for open Heller myotomy.
An image depicting Heller myotomy can be seen below.
Pneumatic dilation, with its 2% risk of perforation, was historically the first choice for achalasia treatment, with surgery reserved for failures. Calcium channel blockers and long-acting nitrates have been attempted as medical therapy to reduce LES tone but are relatively short-acting, do not improve LES relaxation in response to swallowing, have significant side effects (such as headache), and have little overall success. Botox injections can be temporarily successful, primarily in older patients.
The primary indication for Heller myotomy is benign achalasia with dysphagia. Achalasia is a relatively rare condition (prevalence approximately 1/100,000 in western countries ), usually with unknown etiology. It consists of a hypertensive, nonrelaxing lower esophageal sphincter (LES) with a hypoperistaltic or aperistaltic esophageal body.
The pathophysiology is likely secondary to abnormal innervations (inhibitory nonadrenergic, noncholinergic ganglion cell degeneration, and neural fibrosis) of the myenteric plexus. Concurrent significant decreases in synthesis of nitric oxide and vasoactive intestinal peptide (mediators of relaxation) have been noted. Autoimmune, viral, and protozoan (Chagas disease from trypanosoma cruzi in South America) causes have also been attributed as causes of achalasia.
Presenting symptoms have an insidious onset (usually over a duration of at least 2 years) and include progressive dysphagia, regurgitation, chest pain or heart burn, aspiration, and weight loss. Diagnosis is based on a failure of the LES to completely relax with swallowing, confirmed via esophageal manometry (criterion standard), a contrast esophagram, or esophagoscopy. The classical description radiologically is a "bird's beak" narrowing of the esophagus observed during a contrast esophagram.
Indications for surgery in patients with achalasia include: young patients (< 40 years) who will require life-long dilations or Botox injections, patients with recurrent or persistent symptoms after multiple nonsurgical treatments, patients who choose surgery initially, and patients who are high risk for perforation with pneumatic dilation (previous surgery in the gastroesophageal junction [GEJ]). After the need for surgery is determined, indications for open versus laparoscopic approaches are considered (discussed below).
Heller myotomy is contraindicated in patients with prohibitive surgical risk factors or who refuse surgery. Previous pneumatic dilation should not be considered a contraindication to performing Heller myotomy.
Role of fundoplication
The topic is still controversial but the literature largely supports Heller myotomy to be followed by partial (180⁰) fundoplication.[3, 1] Fundoplication is performed to reduce postoperative gastroesophageal reflux (GERD). Adding fundoplication does not add significant time or morbidity to the procedure, and it decreases reflux without increasing dysphagia.
An anterior (Dor) fundoplication is preferred over posterior (Toupet) because less dissection is required. Some reports recommend fundoplication only when the myotomy is carried extensively onto the cardia. Heller myotomy usually does not require fundoplication when performed via thoracotomy or thorascopically, but a “2-stitch” Belsey (instead of the usual 3-stitch procedure, which creates a 180 º fundoplication) is recommended if one is performed. 360 º fundoplications are advised against to avoid outflow obstruction.
Open vs laparoscopic approaches
Currently, the procedure of choice is laparoscopic Heller myotomy. A laparoscopic approach provides less postoperative morbidity and shorter hospital stays with improved response rates (>90%) over thoracoscopic approaches. The literature also supports laparoscopic over open procedures with equivalent or better surgical outcomes and superior quality of life measures.
Open procedure is reserved for special cases when achalasia is associated with epiphrenic diverticula, the patient has undergone a previously failed Heller myotomy, a laparoscopic procedure is seen as not feasible, or when intra-abdominal pathology that is not amenable to laparoscopic treatment is associated. Thoracic approach is recommended when a patient has had multiple prior abdominal operations, a failed transabdominal myotomy, or diffuse esophageal dysmotility.
Role of esophagogastrectomy
Patients with long-standing end-stage motor disorders have more severe symptoms of food stasis, marked esophageal dilation, regurgitation, and aspiration. Patients that have mega-esophagus (>8 cm) also have no esophageal function. Both these groups are typically best managed with an esophagogastrectomy. The reconstruction can be performed with stomach, jejunum, or colon, depending on patient anatomy, surgical history, and age among other factors. Robotic technology is being investigated for its usefulness in Heller myotomy because of the advantages of its 3-dimensional visualization. However, it is costly and additional study is necessary.[8, 9]
See the list below:
Anesthesia: Rapid sequence induction of general anesthesia
Equipment: Standard laparoscopic, laparotomy, or thoracotomy instruments
Patient should be on a clear liquid diet for 48 hrs and NPO after midnight, prior to surgery.
Patients should undergo preoperative manometry to determine proximal extent of manometry
Botulinum toxin injection presurgery creates fibrosis and increases risk of mucosal perforation during dissection.
Begin with an upper midline or left paramedian incision. A general exploration of the abdomen is undertaken, with particular attention to the duodenal wall for evidence of scarring or deformity. The left lobe of the liver is then mobilized by dividing the triangular ligament to expose the lower esophagus. Small bands between the stomach and spleen are also divided to avoid tearing of the splenic capsule. The xyphoid may require excision to obtain adequate exposure. Peritoneum over the esophagus is divided and the stomach is retracted downward. The gastrohepatic ligament is clamped and divided to allow anterior mobilization of the esophagogastric junction. The phrenoesophageal ligaments are divided, and the esophageal fat pad is excised. The surgeon's finger is then passed around the esophagus to finalize freeing the esophagus and illuminating the constricted portion.
All tissue can be cleared from the anterior surface of the esophagus with right angle clamps, dividing any blood vessels. The NG-tube should be aspirated during this portion of the procedure. The myotomy is made by dividing all of the circular and longitudinal (collar-sling) muscular fibers above the area of constriction. The incision is extended 4-6 cm on the esophagus and 1.5-3 cm onto the gastric cardia to reduce outflow resistance. The muscularis should be "undermined" to allow wide separation of esophageal muscles but avoid making an incision entirely through mucosa.
Intraoperative esophagoscopy is widely used for determining length and depth or adequacy of the myotomy. Intraoperative manometry and use of the foley catheter (to make myotomy incision over balloon, and to distend the constricted segment) have been described but are infrequently clinically used.
Search for inadvertent enterotomies through mucosa is conducted, and repaired with silk if found. At this point, pyloroplasty or posterior gastroenterostomy is performed if vagotomy was done. Some prefer to do pyloroplasty on all patients. The foley catheter can be maintained to act as a temporary gastrostomy, after securing tube and anchoring stomach to the abdominal wall. Fascia and skin closure is then completed.
Symptom improvement is reported in an average of 83% of patients undergoing transabdominal open Heller myotomy. Objectively, a 74% decrease in LES pressure was seen. Other sources report permanent relief of dysphagia rates to be expected in 85-100% of patients. One literature review found that the length of gastric myotomy did not influence postoperative results by literature review of transthoracic and transabdominal open procedures. However, performing fundoplication improved both symptomatology and pH monitoring results.
The most significant early complication is mucosal perforation, and it should be identified and repaired intraoperatively. Late complications include GERD and dysphagia. Reflux is common (12%), especially when no concomitant fundoplication is performed. Peptic strictures, Barrett’s esophagus, and persistent dysphagia are also possible complications after Heller myotomy.
Long-term monitoring is not required as recurrence of symptoms can suffice.
Patient is maintained NPO for 24-72 hours with intravenous fluids and parenteral analgesia. A Gastrografin swallow is performed to confirm no extravasation of contrast, and a barium swallow is performed to detect obstruction. Clear liquids are started after negative tests, and diet is advanced as tolerated. Patient is prescribed PO analgesics and stool softener upon discharge.
A failed myotomy, defined as high LES pressure with persistent symptoms, may be best treated with pneumatic dilation attempts. However, reoperation is required in 2.9% of open Heller's myotomy. According to a study of the literature by Gouda et al, the reasons for reoperation were incomplete myotomy (51.85), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (2.03%). Reoperative myotomy is a reasonable option for patients with symptoms of dysphagia, an elevated LES pressure by manometry, and reasonably preserved esophageal motility. Reoperation can be attempted laparoscopically, depending on adhesions. Entering the field through the thorax may provide cleaner dissection.
Reason for failure is cited as a myotomy that is not long or deep enough or due to gastroesophageal reflux and its complications (stricture). Treatment for inadequate myotomy consists of performing a second myotomy, with a subsequent nonobstructive antireflux repair.
Treatment of strictures may include esophagogastrostomy, esophagogastrectomy, cardioplasty, jejunal or colon interposition, or subtotal gastrectomy. Esophagogastrectomy is also sometimes offered to patients with persistent dysphagia and significant esophageal dilatation.
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