Laparoscopic Heller Myotomy
Laparoscopic Heller myotomy (achalasia)
What is it?
Achalasia is the most common functional disorder of the esophagus, resulting from an inability of the lower esophageal sphincter muscle to relax and thus causing difficulty swallowing. If left untreated, achalasia can lead to an increased risk for developing esophageal cancer.
What causes it?
Achalasia is caused by an alteration in the normal neural anatomy of this part of the esophagus. The exact cause of this alteration is unknown, but could include trauma, stress, and certain parasitic infections.
What are the Symptoms?
The most common symptom of achalasia is difficulty swallowing, sometimes to the point of regurgitating previously consumed food. Pain in the chest may occur, but this is less common.
How is it Diagnosed?
The diagnostic work-up first includes an upper GI barium study, which will outline the shape of the esophagus on an x-ray and typically shows a “bird’s beak” tapered appearance. Endoscopy of also performed to evaluate the esophageal lining. The diagnosis is confirmed by measuring the strength of the esophageal muscles (manometry) in order to demonstrate the lack of relaxation and abnormal wave of contractions which are characteristic of achalasia.
Treatment Options
Achalasia may be treated be medications that decrease the tone of the lower esophagus, or by the direct injection of relaxing agents such as botulinum toxin into the muscle. These typically provide only temporary relief. More invasive techniques involve the use of dilators inserted with the aid of an endoscope to stretch the lower esophagus and permit the passage of food.
The surgical treatment of achalasia is called a Heller myotomy. This is a procedure in which the muscles surrounding the lower esophagus are visualized and cut. Traditionally this surgery was performed through an incision in the chest. Over the past decade the laparoscopic approach has gained favor as the preferred technique. This is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to perform the myotomy through several tiny incisions, most of which are less than a half-centimeter in size. The concept of the surgery remains the same as the open approach. The esophageal muscles are visualized and cut while taking care to preserve the inner lining of the esophagus. Typically part of the stomach is then wrapped partially around the esophagus in order to prevent reflux symptoms. The advantages of this method include a shorter hospitalization, less pain, fewer and smaller scars, and a shorter recovery.
Laparoscopic Heller myotomy is a safe and effective treatment for achalasia. However, in the presence of adhesions or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications.
Other complications, although rare, include bleeding and infection. It is uncommon to require a blood transfusion for this operation. There is a risk of injury to the esophagus, liver, stomach, bowel, and spleen. Post-operatively rare problems may occur, mainly involving difficulty with swallowing.
In an otherwise healthy person, little is required to prepare for surgery. Depending on your age, gender, and health problems, some routine blood tests, an EKG and a chest x-ray may or may not be needed. Your surgeon or family doctor will order these tests as needed. You will be asked to refrain from eating 8 hours before surgery. Be sure to let your doctor know what medications you are taking, as some will need to be stopped before surgery. In general, all blood thinners need to be stopped for several days. These include aspirin, Ibuprofen or Motrin, Coumadin and Plavix.
This operation is generally performed with general anesthesia. An IV line will be placed in your arm for fluids and you will be brought into the operation room. The anesthesiologist and nurses will use monitors to check your heart rate and breathing during the procedure. These may include EKG leads, a blood pressure cuff, an oxygen mask and sleeves on your legs to prevent clots from forming.
Once you are asleep, the operating room team will work together to perform your operation. When your operation is complete, you will be awakened from anesthesia in the operating room but you may not remember this. After a few hours in the recovery room you will be transferred to the surgical ward. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts. At the Ohio State University Medical Center most patients remain in the hospital for 2-3 days following the surgery. You will gradually be allowed to increase your intake by mouth, first liquids only followed by soft then regular solid food. Once your surgeon feels your recovery has been appropriate, meaning you are able to eat and drink adequate quantities and you pain is adequately controlled with pills, you will be discharged to home.
You may experience pain at the incision sites and in the chest, as well as mild difficulties swallowing. You will be provided with a prescription for narcotic pain medicine. You should take a stool softener in conjunction with this pain medicine in order to prevent constipation. Heavy lifting of greater than 10 lbs or any strenuous physical activity should be avoided until your follow-up appointment. Driving should be avoided particularly while taking narcotic pain medication. Symptoms that should prompt an immediate call the your surgeon include severe pain, fever of > 101 F, inability to swallow, vomiting, redness or drainage at the incision sites, or shortness of breath.
This information is not intended to replace a visit with your physician. If you have further questions, please call 614-293-3230.