Esophagus: Heller Myotomy

Heller Myotomy

Basics

  • Esophagogastric Myotomy Used for Motility Disorders
  • Most Effective in Achalasia

Procedure for Achalasia

  • Approach:
    • Traditionally Open Anterior & Later a Left Thoracotomy
    • Laparoscopic (Now Gold Standard)
  • Start with Upper Endoscopy
    • Evaluates for Residual Food
    • Assessment During Operation
    • Evaluate Mucosal Integrity After Myotomy
  • Define/Mobilize Esophagus
    • Open Gastrohepatic Ligament to Visualize Right Crura
    • Incise Phrenoesophageal Membrane at 10 O’clock Position Along Right Crura
      • Extend Clockwise to Define the Anterior Aspect
    • Evaluate for Hiatus
      • If Hiatal Hernia Present: Mobilize Posterior Attachments
      • If No Hiatal Hernia: Leave Posterior Attachments Intact
    • Dissect Fat Pad to Expose Anterior Surface
  • Myotomy
    • Start Myotomy 2 cm Proximal to GE Junction
    • Divide Muscle Until Submucosa is Seen
    • Extend 5-6 cm Proximal to GJ Junction & 2 cm Distally onto Stomach Cardia
    • Dissect Muscle Fibers from Mucosa to Expose ≥ 50% of Mucosal Circumference
  • Partial Fundoplication

Heller Myotomy; (A) Myotomy, (B) Dor Fundoplication 1

Procedure Considerations for DES or Nutcracker Esophagus

  • Length of Esophageal Body Myotomy
    • Many Recommend Long Thoracic Myotomy – Requires Right Thoracotomy
  • Inclusion of EG Junction in Myotomy
  • Concomitant Fundoplication

Complications

  • Most Common Complication: Reflux
  • Intraoperative Bleeding
    • Commonly from Tearing of Muscle Fibers
    • Stop with Direct Pressure (Not Electrocautery – Causes Delayed Thermal Injury)
  • Bleeding
  • Sigmoid Esophagus
    • Postoperative Dysphagia with No Obstruction
    • Tx: Esophagectomy
  • Perforation
    • Tx: Repair Perforation & Repeat Myotomy on Opposite Wall

References

  1. Ramirez M, Patti MG. Changes in the diagnosis and treatment of achalasia. Clin Transl Gastroenterol. 2015 May 21;6(5):e87. (License: CC BY-NC-ND-4.0)