Heller myotomy

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Heller myotomy is a surgical procedure in which the muscles 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.

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 (thoracotomy) 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.

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 muscosal layer intact.

There is a small risk of perforation during the myotomy. A barium 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, the fundus of the stomach is wrapped over the front of the esophagus and stitched into place. In Toupet or posterior fundoplication, the fundus is passed around the back of the esophagus instead. Nissen or complete fundoplication (wrapping the stomach 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. In the U.S., some surgeons who have performed over 50 laparoscopic Heller myotomies (listed alphabetically by city) are at Chicago (Soper), Cleveland, OH (Rice), Los Angeles (DeMeester, Maish), Nashville, TN (Richards, Torquati), New York City (Altorki, Salky), Omaha, NE (Mittal), Rochester, NY (Peters), Rochester, MN (Cassivi, Deschamps), Pittsburgh, PA (Luketich), San Francisco (Patti), Seattle, WA (Pellegrini), St. Louis, MO (Matthews), and Tampa, FL (Rosemurgy). There are others, and this is by no means an exhaustive list. An author search at Google Scholar can reveal whether a surgeon has published studies on his/her past experience with a large number of 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 about a week. 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 leading to a premalignant condition known as Barrett's esophagus and increasing the risk of cancer.

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.

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