Overview
Definition:
Heller myotomy with fundoplication is a surgical procedure performed to treat achalasia cardia, a primary esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and loss of peristalsis in the esophageal body
The Heller myotomy involves a myotomy (cutting) of the muscle fibers of the LES, while the fundoplication (wrapping of the gastric fundus around the distal esophagus) is performed to prevent gastroesophageal reflux, a common complication after myotomy.
Epidemiology:
Achalasia cardia is a rare disorder with an estimated incidence of 1 in 100,000 people
It can occur at any age but is most commonly diagnosed in individuals between the ages of 30 and 60 years
There is a slight female preponderance.
Clinical Significance:
Untreated achalasia leads to progressive dysphagia, regurgitation, chest pain, and weight loss, significantly impacting a patient's quality of life
Long-standing achalasia is also associated with an increased risk of esophageal cancer
Surgical intervention, such as Heller myotomy with fundoplication, is the mainstay of treatment for symptomatic achalasia, aiming to restore esophageal transit and improve symptom control.
Indications
Surgical Indications:
Symptomatic achalasia cardia refractory to medical management or pneumatic dilation
Significant weight loss or malnutrition due to dysphagia
Recurrent aspiration pneumonia
Patients seeking definitive treatment for long-standing symptoms
Failure of previous pneumatic dilation.
Contraindications:
Severe comorbidities that make surgery too risky
Advanced achalasia with sigmoid esophagus and severe esophageal dilation
Active peptic ulcer disease
Uncontrolled gastroesophageal reflux disease (GERD) without achalasia
Previous extensive esophageal surgery in the region.
Preoperative Preparation
Diagnostic Workup:
Barium swallow to assess esophageal dilation, strictures, and Chicago classification
Esophageal manometry to confirm diagnosis and assess LES pressure and esophageal peristalsis
Upper endoscopy to rule out mechanical obstruction and obtain biopsies
Consider CT scan for advanced disease or suspicion of malignancy.
Patient Optimization:
Nutritional assessment and optimization
Consultation with a dietitian if significant weight loss is present
Review of medications, particularly those affecting esophageal motility or LES pressure
Smoking cessation advice
Preoperative antibiotics as per institutional protocol
Anesthesia assessment and optimization.
Informed Consent:
Detailed discussion with the patient regarding the procedure, its benefits, risks, and potential complications
Explanation of the need for both myotomy and fundoplication
Discussion of alternative treatment options
The need for lifelong follow-up.
Procedure Steps
Surgical Approach:
Laparoscopic Heller myotomy with Nissen fundoplication is the preferred approach due to reduced morbidity, shorter hospital stays, and faster recovery
Open transthoracic or transabdominal approaches are reserved for specific complex cases or when laparoscopy is not feasible.
Laparoscopic Heller Myotomy:
The surgeon makes several small incisions in the abdomen
The esophagus is dissected, and a longitudinal myotomy is performed on the anterior or posterior aspect of the distal esophagus and LES, extending approximately 4-6 cm proximally
Care is taken to avoid transecting the esophageal mucosa
The muscularis mucosa is also partially divided.
Fundoplication:
A 360-degree Nissen fundoplication is typically performed, where the gastric fundus is mobilized and wrapped around the distal esophagus
This helps to buttress the myotomy and prevent gastroesophageal reflux
Other types of partial fundoplication (e.g., Toupet) may be considered in specific situations.
Intraoperative Checks:
Confirmation of adequate myotomy length
Assessment of LES relaxation with intraoperative manometry if available
Check for any mucosal tears
Confirmation of secure fundoplication
Leak test with air insufflation or methylene blue dye instillation if a mucosal tear is suspected.
Postoperative Care
Pain Management:
Adequate analgesia, typically using patient-controlled analgesia (PCA) or intravenous/oral opioids, followed by NSAIDs
Epidural analgesia may be used in open procedures.
Dietary Advancement:
Clear liquids are initiated 24-48 hours postoperatively after a trial of air insufflation or a swallow study to rule out leaks
Diet is gradually advanced to soft, then regular as tolerated, with emphasis on small, frequent meals and avoiding triggers for reflux or dysphagia.
Monitoring:
Close monitoring for signs of bleeding, infection, anastomotic leak, or bowel obstruction
Respiratory monitoring to prevent atelectasis and pneumonia
Early mobilization to prevent deep vein thrombosis and pulmonary complications.
Discharge Criteria:
Tolerating an oral diet
Adequate pain control with oral analgesics
Ambulating independently
Absence of significant nausea, vomiting, or abdominal distension
Satisfactory vital signs.
Complications
Early Complications:
Esophageal leak (most serious)
Bleeding
Pneumonia
Atelectasis
Wound infection
Injury to surrounding organs (spleen, liver, diaphragm)
Gastric outlet obstruction
Injury to the vagus nerve.
Late Complications:
Gastroesophageal reflux disease (GERD) despite fundoplication
Recurrent dysphagia due to incomplete myotomy or scarring
Esophageal dysmotility
Gas bloat syndrome (difficulty belching and bloating)
Diaphragmatic hernia
Weight loss.
Prevention Strategies:
Meticulous surgical technique to avoid mucosal injury during myotomy
Adequate length of myotomy to ensure LES relaxation
Secure and appropriate fundoplication to prevent reflux
Postoperative dietary modifications to aid healing and prevent reflux
Judicious use of proton pump inhibitors (PPIs) if significant reflux occurs
Close follow-up to identify and manage late complications.
Prognosis
Factors Affecting Prognosis:
The success rate of Heller myotomy with fundoplication is generally high, with symptom relief reported in 80-95% of patients
Factors influencing prognosis include the duration and severity of achalasia, surgical technique, completeness of the myotomy, and the skill of the surgeon
Early diagnosis and intervention lead to better outcomes.
Outcomes:
Most patients experience significant improvement in dysphagia and regurgitation, leading to weight gain and improved quality of life
Long-term recurrence of symptoms can occur, necessitating further intervention
The risk of GERD needs to be managed
The risk of esophageal cancer remains elevated in the long term compared to the general population.
Follow Up:
Regular long-term follow-up is crucial to monitor for symptom recurrence, GERD, and to screen for esophageal cancer
This typically involves clinical assessment and may include intermittent upper endoscopy or manometry
Patients should be educated on long-term dietary recommendations and lifestyle modifications.
Key Points
Exam Focus:
Achalasia is a primary esophageal motility disorder of LES relaxation and esophageal peristalsis
Heller myotomy severs the LES muscle, and fundoplication prevents reflux
Laparoscopic approach is standard
Complications include leak, bleeding, and GERD
Long-term follow-up is vital.
Clinical Pearls:
Always perform a complete myotomy extending to the gastroesophageal junction and slightly onto the stomach
A full 360-degree Nissen fundoplication is often preferred to prevent reflux, but partial fundoplications may be considered in patients with significant pre-existing reflux symptoms or when a very floppy esophagus is encountered
Consider intraoperative manometry to confirm LES relaxation post-myotomy.
Common Mistakes:
Incomplete myotomy leading to persistent dysphagia
Esophageal perforation during myotomy
Inadequate fundoplication leading to severe reflux
Overly tight fundoplication causing gastric outlet obstruction or dysphagia
Failure to consider alternative diagnoses like pseudoachalasia.