Open Heller Myotomy Periprocedural Care

Updated: Mar 24, 2017
  • Author: Adriana Laser, MD, MPH; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Preprocedural Planning

Role of fundoplication

Although some controversy remains, the literature largely supports following Heller myotomy with partial (180⁰) fundoplication. [11, 1]  Fundoplication is performed to reduce postoperative gastroesophageal reflux (GER). Adding fundoplication does not add significant time or morbidity to the procedure, and it decreases GER without increasing dysphagia.

An anterior (Dor) fundoplication is preferred to a posterior (Toupet) fundoplication because less dissection is required. Some reports recommend fundoplication only when the myotomy is carried extensively onto the cardia. [10]  Heller myotomy usually does not require fundoplication when performed via thoracotomy or thorascopically, but a two-stitch Belsey (instead of the usual three-stitch procedure, which creates a 180º fundoplication) is recommended if one is performed. To avoid outflow obstruction, 360º fundoplications are not recommended.

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 who have a megaesophagus (>8 cm) also have no esophageal function. Both of these patient groups typically are best managed with an esophagogastrectomy. The reconstruction can be performed with stomach, jejunum, or colon, depending on the patient's anatomy, surgical history, and age, among other factors. [12]

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Equipment

Heller myotomy is performed with standard laparoscopic, laparotomy, or thoracotomy instruments.

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Patient Preparation

Rapid sequence induction of general anesthesia is employed. The patient is placed in the supine position.

The patient should be on a clear liquid diet for 48 hours and should receive nothing orally after midnight before the operation. Preoperative manometry should be done to determine the proximal extent of the procedure.

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