A Heller myotomy, also called esophagomyotomy, is a surgical procedure during which the muscles of the lower part of the esophagus are cut. This operation is used to treat a condition called “achalasia,” in which spasms of the esophagus prevent the normal passage of liquids and food into the stomach.
The esophagus is a muscular tube leading from the throat into the stomach. The upper zone of the esophagus is attached to the throat. It is a muscular ring referred to as the “upper esophageal sphincter,” or UES, and is responsible for preventing swallowed food and liquid from passing upward from the esophagus and back into the throat. The lowest area of the esophagus is referred to as the “lower esophageal sphincter,” or LES. This area joins with the upper part of the stomach, the cardia. A swallowing disorder is the result of the LES’s inability to relax. Cutting the LES can relieve this problem, allowing normal eating and drinking to take place.
Achalasia can be either primary or secondary. Primary achalasia occurs on its own, and is a disorder of the LES itself; no other underlying disorder accounts for the condition. Secondary achalasia occurs when there is another disease that has affected LES functioning. The two most common underlying conditions that can result in achalasia are esophageal cancer and Chagas disease. Symptoms of achalasia include difficulty swallowing, regurgitation, and weight loss.
Men are three to four times more likely to develop esophageal cancer than are women, and African-Americans are about 50% more likely to develop the condition. According to the American Cancer Society, about 16,470 new cases of esophageal cancer will be diagnosed in the United States in 2008, and the disease will be responsible for about 14,280 deaths. The disease is much more common in other countries, such as Iran, northern China, India, and southern Africa, where rates are between ten and 100 times as high as they are in the United States. Still, esophageal cancer rates among white men in Western countries are increasing steadily, at a rate of about 2% per year; the rate has held steady among white women. Among patients diagnosed at all stages of esophageal cancer, five-year survival rates are about 18% in white patients and 11% in African-American patients.
Chagas disease is a parasitic disease found primarily in South America. This protozoan infection is passed to humans during the bite of a bug colloquially referred to as an “assassin bug.” It can also be acquired during infected blood transfusions, when food is infected with the protozoa, and by a fetus if its mother is infected. Chagas disease has two phases, acute and chronic. It is during the chronic phase that the lower esophageal sphincter may be affected, causing achalasia.
Achalasia often requires treatment because it can cause a number of complications. Patients with achalasia often suffer from the discomfort of heartburn or gastroesophageal reflux disease. Additionally, the constant exposure of the vulnerable lining of the esophagus to a backwash of stomach acid may result in a condition called Barrett’s esophagus. This occurs when the lining cells begin to take on pre-malignant characteristics, and patients have a high risk of eventually developing esophageal cancer. When foods and liquids cannot be fully swallowed, they may also be sucked into the lungs, putting the individual at risk for aspiration pneumonia.
Patients who are taking blood thinners, aspirin, or nonsteroidal anti-inflammatory medications may need to discontinue their use in advance of the test, to avoid increasing the risk of bleeding.
Patients undergoing Heller myotomy require general anesthesia. This will be administered in the form of intravenous medications as well as anesthetic gasses that are inhaled. The patient will be intubated and on a ventilator for the duration of the surgery.
A Heller myotomy can be achived through a traditional upper abdominal incision, or through multiple very small laparoscopic incision. These days, the laparasopic approach is most common. Laparoscopic Heller myotomy involves the introduction of a videoscope through one of the keyhole incisions, and the use of other tiny incisions for introducing the miniature surgical instruments necessary for the operation. Once the esophagus is accessed, a lengthwise incision through the outer muscular layer is made. Sometimes, a bit of the stomach is wrapped around the lower part of the esophagus and secured, to try to avoid further gastric reflux. This is referred to as a fundoplication.
Patients will need to stop eating and drinking for about 12-16 hours prior to their operation. The evening before the operation, a series of enemas and/or laxatives are used to empty the GI tract of feces. An intravenous line will be placed in order to provide the patient with fluids, general anesthesia agents, sedatives, and pain medicines during the operation. A urinary catheter will be placed in the patient’s bladder. The patient will be attached to a variety of monitors to keep track of blood pressure, heart rate, and blood oxygen level throughout the procedure.
The hospital stay after Heller myotomy is usually 2-3 days. Clear liquids are introduced on the same day as the surgery, and within a few days the patient will be allowed to begin taking soft foods. Over time, the patient’s diet will slowly be reinstated, progressing gradually from liquids to soft foods to solids. If swallowing remains problematic, a therapist specializing in re-teaching swallowing may be needed to help design a rehabilitative program.
During the course of a Heller myotomy, there is some risk that the esophagus will become perforated by one of the surgical instruments. Patients who have had a Heller myotomy have a continued high risk of gastric esophageal reflux. Many patients require re-treatment, either another myotomy or removal of a section of esophagus (esophagectomy).
The risk of perforation during Heller myotomy is about 1%. The risk of death is about 0.2%. In general, studies have shown that hospital and surgeon experience with esophagogastrectomy reduces the risk of morbidity and mortality for patients.
Normal results occur when the overly tight LES is released, allowing the normal passage of food and liquids through the esophagus and into the stomach.
Abnormal results include a continued inability to swallow or inadvertent perforation of the esophagus during surgery.
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Rosalyn Carson-DeWitt, MD