Heller myotomy is a

surgical Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery ...

procedure in which the

muscle Muscle is a soft tissue, one of the four basic types of animal tissue. There are three types of muscle tissue in vertebrates: skeletal muscle, cardiac muscle, and smooth muscle. Muscle tissue gives skeletal muscles the ability to muscle contra ...

s of the

cardia The stomach is a muscular, hollow organ in the upper gastrointestinal tract of humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical terms re ...

(

lower esophageal sphincter The esophagus (American English), oesophagus (British English), or œsophagus ( archaic spelling) ( see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), colloquially known also as the food pipe, food tube, or gullet, ...

or LES) are cut, allowing food and liquids to pass to the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

. It is used to treat

achalasia Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esopha ...

, a disorder in which the lower esophageal

sphincter A sphincter is a circular muscle that normally maintains constriction of a natural body passage or orifice and relaxes as required by normal physiological functioning. Sphincters are found in many animals. There are over 60 types in the human bo ...

fails to relax properly, making it difficult for food and liquids to reach the stomach.

History and development

It was first performed by Ernst Heller (1877–1964) in 1913. Then and until recently, this surgery was performed using an open procedure, either through the chest (

thoracotomy A thoracotomy is a surgical procedure that involves cutting open the chest wall to gain access into the pleural cavity, It is mostly performed by specialist cardiothoracic surgeons, although emergency physicians or paramedics occasionally also ...

) or through the abdomen (

laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...

). However, open procedures involve greater recovery times. Modern Heller myotomy is normally performed using

minimally invasive Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definitio ...

laparoscopic Laparoscopy () is an operation performed in the abdomen or human pelvis, pelvis using small Surgical incision, incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few ...

techniques, which minimize risks and speeds recovery significantly. The 100th anniversary of Heller's description of the surgical treatment of patients with achalasia was celebrated in 2014.

Procedure

During the procedure, the patient is put under

general anaesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analges ...

. Five or six small incisions are made in the

abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the vi ...

and laparoscopic instruments are inserted. The myotomy is a lengthwise cut along the

esophagus The esophagus (American English), oesophagus (British English), or œsophagus (Œ, archaic spelling) (American and British English spelling differences#ae and oe, see spelling difference) all ; : ((o)e)(œ)sophagi or ((o)e)(œ)sophaguses), c ...

, starting usually about 6 cm above the lower esophageal sphincter and extending down onto the stomach approximately 2-2.5 cm. The oesophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact. This procedure can also be performed robotically.

Risks, complications, and outlook

There is a small risk of perforation during the myotomy. A gastrografin 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 oesophageal 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 Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or ...

. In Dor or anterior fundoplication, which is the most common method, part of the stomach (the fundus) is laid over the front of the oesophagus and stitched into place so that whenever the stomach contracts, it also closes off the oesophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the oesophagus instead. Nissen or complete fundoplication (wrapping the fundus all the way around the oesophagus) is generally not considered advisable because

peristalsis Peristalsis ( , ) is a type of intestinal motility, characterized by symmetry in biology#Radial symmetry, radially symmetrical contraction and relaxation of muscles that propagate in a wave down a tube, in an wikt:anterograde, anterograde dir ...

is absent in achalasia patients. This is a somewhat challenging operation, and surgeons have reported improved outcomes after their first 50 patients. An author search a
Google Scholar
can be used to find studies on a surgeon's past experience with achalasia patients. After laparoscopic surgery, most patients can take clear liquids later the same day, start a

soft diet A mechanical soft diet or edentulous diet, or soft food(s) diet, is a diet that involves only foods that are physically soft, with the goal of reducing or eliminating the need to Mastication, chew the food. This is also commonly referred to as ...

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 two weeks. 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 oesophagectomy. It is important to monitor changes in the shape and function of the esophagus with an annual timed

barium swallow An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as bariu ...

. Regular

endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...

may also be useful to monitor changes in the tissue of the oesophagus, since reflux may damage the oesophagus over time, potentially causing the return of

dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...

, or a

premalignant condition A precancerous condition is a condition, tumor or lesion involving abnormal cells which are associated with an increased risk of developing into cancer. Clinically, precancerous conditions encompass a variety of abnormal tissues with an increase ...

known as

Barrett's esophagus Barrett's esophagus is a condition in which there is an abnormal ( metaplastic) change in the mucosal cells that line the lower part of the esophagus. The cells change from stratified squamous epithelium to simple columnar epithelium, intersper ...

. Though this surgery does not correct the underlying cause and does not 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.

References

External links

UpToDate Patient Information: Achalasia
{{Muscle/soft tissue procedures Digestive system surgery

History and development

Procedure

Risks, complications, and outlook

See also

References

External links