Laparoscopic Heller Myotomy/Cardiomyotomy
Penn State Hershey Minimally Invasive surgeons are treating achalasia of the esophagus using the minimally invasive Heller Myotomy technique. Benefits of this approach include five small incisions instead of one large abdominal incision, shorter hospital stay, reduced postoperative pain and a shorter recovery time of a few days.
Laparoscopic cardiomyotomy (Heller myotomy) is performed for achalasia. Achalasia is a primary esophageal motility disorder of unknown etiology. It is characterized by progressive loss of peristalsis in the body of the esophagus and failure of a normal or hypertensive lower esophageal sphincter (LES) to relax upon swallowing. No form of treatment returns the esophageal peristalsis or the LES function back to normal. Instead, therapy is aimed at relieving the functional obstruction at the gastroesophageal junction.
Patients with achalasia present with progressive dysphagia and weight loss. Pain is uncommon. The diagnostic workup must exclude several diseases that can mimic achalasia. These include malignant obstruction, gastroesophageal reflux with stricture formation, diffuse esophageal spasm, and nutcracker esophagus, A complete diagnostic workup is outlined in the table below.
Diagnostic workup for laparoscopic cardiomyotomy:
|Test||Results Consistent with Achalasia|
|Barium swallow||Dilated esophagus, tapering distally, with a so-called birds beak deformity|
|Upper GI Endoscopy (EGD) with biopsy if necessary||Smooth mucosa and a tight distal esophageal sphincter which the endoscopist is able to traverse.|
|Esophageal manometry||Loss of peristalsis in the esophageal body and a normal or hypertensive lower esophageal sphincter that fails to relax upon swallowing|
|24-hour pH study*||No evidence of gastroesophageal reflux|
|Computed tomography (CT) scan*||No evidence of malignancy|
*Optional tests, depending upon clinical presentation.
There are several therapeutic options once achalasia is definitively diagnosed. Patients who can tolerate general anesthesia are candidates for laparoscopic cardiomyotomy. Pneumatic balloon dilation is an alternative treatment. Botulinum toxin (BOTOX) injection is an alternative that should be reserved for patients who are not candidates for operation or dilatation.
Who should be referred for laparoscopic cardiomyotomy?
- Young patients - patients under the age of 40 do not respond well to pneumatic dilation
- Patients who fail pneumatic dilations
- Patients who are fit for surgery and choose to have surgery
Because patients with achalasia frequently retain food and secretions within the esophagus, preoperative fasting for at least 8 hours is recommended. Candida albicans frequently colonizes this dilated esophagus and preoperative oral antifungal therapy may be warranted. These measures decrease the likelihood of aspiration upon induction of anesthesia, and minimize the consequences of inadvertent mucosal perforation during myotomy.
In the operating room, the patient is supine on the operating table. An orogastric tube and a Foley catheter are usually placed. Most surgeons use sequential pneumatic compression devices (or perioperative low molecular weight heparin injections) as prophylaxis for deep venous thrombosis. The abdomen is inflated with CO 2. Five trocars are placed in the upper abdomen. They are 5 or 10 mm in size.
The procedure begins with an hiatal dissection, followed by the myotomy, and an antireflux procedure (if desired). The hiatal dissection consists of mobilization of the distal esophagus, the gastroesophageal junction, the cardia and the fundus.
The myotomy is performed by separating the outer longitudinal muscle layer and incising the inner circular muscle layer. It is carried proximally about 5-6 cm from the gastroesophageal junction. Distally, the myotomy is carried across the gastroesophageal junction and on to the stomach for about 1-2 cm. Once the submucosal plane is reached, the mucosa bulges up. This is clearly seen in the magnified laparoscopic view. Once the myotomy is completed, the muscle edges are separated from the underlying mucosa for approximately 40% of the esophageal circumference. The orogastric tube is then pulled back into the distal esophagus and methylene blue solution is instilled down the tube. This will clearly demonstrate any mucosal perforation. If any perforation is encountered, it is closed with a stitch.
Reflux is a common problem after conventional cardiomyotomy. Therefore many surgeons (including the author) prefer to add a partial fundoplication (Toupet, a posterior fundoplication or Dor, an anterior fundoplication) at the completion of the myotomy. The partial fundoplication holds the raw edges of the myotomy open and provides some protection against gastroesophageal reflux, while being sufficiently loose not to obstruct passage of food and liquids.
Mucosal perforation is the most common complication. They are easily recognized, if not immediately, then during the installation of methylene blue dye into the esophagus. These lacerations are clean and are easily repaired with a stitch. As of today, there are no reports of an infection from a small, recognized mucosal laceration during laparoscopic cardiomyotomy. Late perforations are very rare.
Pneumothorax is not uncommon during laparoscopic hiatal dissection and esophageal mobilization (approximately 5%). These pneumothoraces are usually small and self-limited. They are best recognized on a postoperative chest film. Intervention is rarely needed as the lung re-expands rapidly as carbon dioxide is absorbed.
Postoperative complications are rare. Persistent dysphagia is the most common postoperative problem, but Heller myotomy offers relief of dysphagia in 90-97% of patients. Postoperative dysphagia may be due to either incomplete myotomy or a megaesophagus in "end-stage" achalasia. Workup of postoperative dysphagia requires careful assessment including a Ba-swallow, endoscopy and esophageal manometry and should prompt reconsideration of the underlying diagnosis. Postoperative dilation can be of help, but if esophageal manometry shows clearly an uncut, high-pressure zone at the gastroesophageal junction, reoperation should be considered. Patients with extremely dilated aperistaltic esophagus generally require esophageal replacement.
Postoperative fever, is most commonly due to pulmonary atelectases. However, aspiration must be considered, as these patients are at risk for aspiration during the induction of anaesthesia. If aspiration is not likely, respiratory therapy with incentive spirometry is generally an adequate treatment. Antibiotics may be required if aspiration is suspected, if the fever persists and in patients with underlying pulmonary problems.
Cardiomyotomy for achalasia is one of the ideal procedures for the laparoscopic approach. Magnification of the operative field during laparoscopic surgery allows for a precise division of the muscle fibers with excellent results. Over the past 5-7 years, numerous reports of laparoscopic cardiomyotomy have been published. They show good-excellent results, with relief of dysphagia in 90-97% of patients, with minimal morbidity, a short hospital stay and early return to routine activity.