Open Heller Myotomy 

Updated: Apr 29, 2019
Author: Adriana Laser, MD, MPH; Chief Editor: Kurt E Roberts, MD 

Overview

Background

In 1913, Ernest Heller reported the first successful cardiomyotomy for achalasia.[1]  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 This transabdominal approach remained the criterion standard in Europe until it was superseded by minimally invasive techniques.[2]

In North America, however, 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 way of performing an open Heller myotomy.

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 lower esophageal sphincter (LES) tone but are relatively short-acting, do not improve LES relaxation in response to swallowing, have significant side effects (eg, headache), and have little overall success. Botulinum toxin injections can be temporarily successful, primarily in older patients.

Indications

The primary indication for Heller myotomy is benign achalasia with dysphagia.[3] Achalasia is a relatively rare condition (prevalence approximately 1/100,000 in Western countries[1] ), and the etiology is usually unknown. It consists of a hypertensive, nonrelaxing LES with a hypoperistaltic or aperistaltic esophageal body.[4]  (See the image below.)

Nonrelaxing lower esophageal sphincter. Nonrelaxing lower esophageal sphincter.

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 conditions, viral infections, and protozoan infections (eg, Chagas disease from Trypanosoma cruzi in South America) 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 failure of the LES to completely relax with swallowing, confirmed by means of esophageal manometry (the criterion standard), contrast esophagography, or esophagoscopy. The classic description radiologically is a "bird's beak" narrowing of the esophagus observed during contrast esophagography.

Surgery is indicated for the following patients with achalasia:

  • Young patients (< 40 years) who will require lifelong dilations or botulinum toxin injections
  • Patients with recurrent or persistent symptoms after multiple nonsurgical treatments
  • Patients who choose surgery initially
  • Patients who are at high risk for perforation with pneumatic dilation (previous surgery in the esophagogastric junction [EGJ])

After the need for surgery is determined, indications for open versus laparoscopic approaches are considered (see Technical Considerations).

Contraindications

Heller myotomy is contraindicated in patients with prohibitive surgical risk factors and in those who refuse surgery. Previous pneumatic dilation should not be considered a contraindication for performing Heller myotomy.

Technical Considerations

Procedural planning

Currently, the procedure of choice is laparoscopic Heller myotomy.[5] A laparoscopic approach provides less postoperative morbidity and shorter hospital stays with improved response rates (>90%) as compared with thoracoscopic approaches.[1] The literature also supports laparoscopic over open procedures, with equivalent or better surgical outcomes and superior quality-of-life measures.[6]

The open procedure is reserved for the following special cases:

  • Achalasia that is associated with epiphrenic diverticula, [7] though laparoscopy is increasingly being considered in this setting as well [8]
  • Patient who has undergone a previous failed Heller myotomy
  • Cases where a laparoscopic procedure is seen as not feasible
  • Presence of associated intra-abdominal pathology that is not amenable to laparoscopic treatment

The thoracic approach is recommended when a patient has undergone multiple prior abdominal operations, has had a failed transabdominal myotomy, or has diffuse esophageal dysmotility.

Robotic technology is being investigated for its usefulness in Heller myotomy because of the advantages afforded by its three-dimensional visualization. However, it is costly, and additional study is necessary.[9]  Peroral endoscopic myotomy (POEM) has also been described.[10, 11, 3]

Complication prevention

Botulinum toxin injection before the surgical procedure creates fibrosis and increases risk of mucosal perforation during dissection.

Outcomes

Symptom improvement is reported in an average of 83% of patients undergoing transabdominal open Heller myotomy.[12]  Objectively, a 74% decrease in LES pressure was seen.[1]  Other sources reported that permanent relief of dysphagia could be expected in 85-100% of patients.[13]  One literature review of transthoracic and transabdominal open procedures found that the length of the gastric myotomy did not influence postoperative results.[14]  However, performing fundoplication improved both symptomatology and pH monitoring results.

 

Periprocedural Care

Preprocedural Planning

Role of fundoplication

Although some controversy remains, the literature largely supports following Heller myotomy with partial (180⁰) fundoplication.[14, 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.[13] 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.[15]

Equipment

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

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.

 

Technique

Heller Myotomy via Open Approach

An upper midline or left paramedian incision is made. A general exploration of the abdomen is undertaken, paying particular attention to the duodenal wall for evidence of scarring or deformity. The left hemiliver 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 xiphoid may have to be excised to afford adequate exposure.

The 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 (EGJ). The phrenoesophageal ligaments are divided, and the esophageal fat pad is excised. The surgeon's finger is then passed around the esophagus to finalize mobilization of the esophagus and to delineate the constricted portion.

All tissue is cleared from the anterior surface of the esophagus with right-angle clamps, and any blood vessels are divided. The nasogastric 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 care must be taken to avoid making an incision entirely through mucosa.

Intraoperative esophagoscopy is widely used for determining the length and depth or adequacy of the myotomy. Intraoperative manometry and use of the Foley catheter (to make the myotomy incision over the balloon and to distend the constricted segment) have been described but are infrequently used in clinical settings.[14]

A search for inadvertent enterotomies through mucosa is conducted, and any such injuries found are repaired with silk. 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 the tube is secured and the stomach anchored to the abdominal wall. Fascia and skin closure is then completed. (See the image below.)

Heller myotomy for achalasia. Heller myotomy for achalasia.

Reoperation for failed myotomy

A failed myotomy, defined as a high lower esophageal sphincter (LES) pressure with persistent symptoms, may be best treated by attempting pneumatic dilation. However, reoperation is required after 2.9% of open Heller myotomies.[16]  According to a study of the literature by Gouda et al, the reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (2.03%).[17]

Reoperative myotomy is a reasonable option for patients with symptoms of dysphagia, an elevated LES pressure by manometry, and reasonably well-preserved esophageal motility. Reoperation can be attempted laparoscopically,[18] depending on the presence and extent of adhesions. Entering the field through the thorax may provide cleaner dissection.

Reasons cited for failure of a myotomy include an incision that is not long or deep enough and the presence of gastroesophageal reflux (GER) and its complications (stricture). Treatment of inadequate myotomy consists of performing a second myotomy, with a subsequent nonobstructive antireflux repair.

Treatment of strictures may include esophagogastrostomy, esophagogastrectomy, cardioplasty, jejunal or colonic interposition, or subtotal gastrectomy. Esophagogastrectomy is also sometimes offered to patients with persistent dysphagia and significant esophageal dilatation.

Postoperative Care

The patient is maintained on NPO (nil per os) status for 24-72 hours and receives intravenous fluids and parenteral analgesics. A diatrizoate meglumine–diatrizoate sodium swallow is performed to confirm that there is no extravasation of contrast, and a barium swallow is performed to detect obstruction. If test results are negative, clear liquids are started, and the patient's diet is advanced as tolerated. At discharge, oral analgesics and a stool softener are prescribed.

Complications

The most significant early complication of open Heller myotomy is mucosal perforation, which should be identified and repaired intraoperatively. Late complications include gastroesophageal reflux disease (GERD) and dysphagia. Reflux is common (12%),[1]  especially when no concomitant fundoplication is performed. Peptic strictures, Barrett esophagus, and persistent dysphagia are also possible complications after Heller myotomy.