Heller Myotomy Maria V. Gorodner, MD, Carlos Galvani, MD, and Marco G. Patti, MD

uring the 1970s and 1980s, it was generally accepted by the medical community that pneumatic dilation was the primary form of treatment of esophageal achalasia, so that surgery was relegated to a supporting role for the failures of pneumatic dilation. As a consequence, even in tertiary care centers the experience was limited to one or two cases per year, mostly for patients who had dysphagia after multiple dilatations, or for those who suffered a perforation at the time of a dilation. The application of minimally invasive surgery to the treatment of esophageal achalasia has delivered an unexpected change in the treatment algorithm of this disease, whereby today a laparoscopic Heller myotomy is considered by most gastroenterologists and surgeons the primary treatment modality, reserving pneumatic dilation to the few failures of this operation (Fig 1). This shift in practice is because of the following factors1-11: (1) minimally invasive surgery replicates the excellent results of open surgery with relief of dysphagia in 85% to 95% of patients; (2) minimally invasive surgery is associated with a shorter hospital stay, minimal postoperative discomfort and a rapid recovery time; and (3) it has become clear that the results of the other forms of treatment for achalasia (botulinum toxin and pneumatic dilation) are clearly inferior to those of surgery and may complicate subsequent operative therapy. As a consequence, during the last decade we have witnessed an increase in the number of patients referred each year for operation, from one or two patients per year in the 1970s and 1980s to 15 to 25 patients per year during the last 5 years. In addition, about 70% of patients we operate today have never been treated before.

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malignancy. In addition, it is important to know if a patient has been previously treated with intrasphincteric injection of botulinum toxin, as fibrosis may develop at the level of the gastroesophageal junction. The consequent loss of anatomic planes makes the operation more difficult and the results less predictable. All patients who are candidates for a laparoscopic Heller myotomy should undergo the following preoperative evaluation.

Barium Swallow In patients with achalasia it often shows distal esophageal narrowing. It also provides important information about the diameter and shape (straight versus sigmoid) of the esophagus.1

Endoscopy It should be done in all patients to rule out a benign or malignant stricture of the distal esophagus, as well as to identify any gastric and duodenal pathology.2

Esophageal Manometry Esophageal peristalsis is always absent. The lower esophageal sphincter is hypertensive in about 50% of patients,

PREOPERATIVE EVALUATION Patients are questioned regarding the presence of dysphagia, regurgitation, chest pain, and heartburn. Because most patients with achalasia are able to maintain their weight, a history of major weight loss in an elderly patient (⬎60 years of age) who has been symptomatic for a short period of time (⬍1 year) should raise the suspicion of a

From the Laparoscopic Surgery, University of California, San Francisco, San Francisco, CA and Center for the Study of Gastrointestinal Motility and Secretion, University of California, San Francisco, San Francisco, CA. Address reprint requests to Marco G. Patti, MD, University of California, San Francisco, 533 Parnassus Avenue, Room U-122, San Francisco, CA 94143-0788. © 2004 Elsevier Inc. All rights reserved. 1524-153X/04/0601-0005$30.00/0 doi:10.1053/j.optechgensurg.2004.01.006

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Treatment algorithm of esophageal achalasia before and after the introduction of minimally invasive surgery.

Operative Techniques in General Surgery, Vol 6, No 1 (March), 2004: pp 23-28

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and usually fails to relax appropriately in response to swallowing.9

Ambulatory pH Monitoring This test should be performed preoperatively in patients who have undergone previous treatment to determine if abnormal reflux is already present. In addition, it should be repeated after the procedure even in asymptomatic patients, as heartburn is present in only 40% of patients who develop abnormal reflux postoperatively.9

Laparoscopic Heller Myotomy and Dor Fundoplication

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Placement of the trocars. Five trocars are used for the operation. Trocar #1 is placed in the midline, 14 cm caudad to the xiphoid process. It is used for the 30° scope. Trocar # 2 is placed in the left mid clavicular line at the same level with the camera. It is used for inserting a Babcock clamp and instruments to divide the short gastric vessels. Trocar # 3 is placed in the right mid clavicular line at the same level as the previous 2 trocars. It is used for the insertion of a retractor to lift the left lateral segment of the liver and expose the gastroesophageal junction. Trocars # 4 and #5 are placed under the right and left costal margins, respectively, so that their axes form an angle of about 120°. These ports are used for the dissecting and suturing instruments. The electrocautery used to perform the myotomy is inserted through trocar #5.

Dissection of the Lower Esophagus and Gastroesophageal Junction

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Positioning of the patient on the operating room table. After induction of general anesthesia with a single lumen endotracheal tube, the patient is positioned supine on the operating table over a beanbag, which is securely fixed to the table. The lower part of the beanbag is used to create a saddle under the patient’s perineum to avoid sliding during the operation when a steep reverse Trendelenburg position is used. The legs are extended on stirrups, with the knees flexed only 20° or 30°. Compression stockings are routinely used. An orogastric tube and a urinary catheter are inserted before the operation and are usually removed at the end of the procedure. The surgeon stands in between the patient’s legs, while the assistants stand on the right and left side of the table.

The operation is started at the level of the caudate lobe of the liver by dividing the gastrohepatic ligament. The right crus of the diaphragm is identified and separated from the esophagus by blunt dissection. The peritoneum and phrenoesophageal membrane overlying the esophagus are transected. The left pillar of the crus is separated by blunt dissection from the esophagus. The dissection is continued in the posterior mediastinum, lateral and anterior, to expose 6 cm to 7 cm of the esophagus. Because an anterior fundoplication is performed after completion of the myotomy, no posterior dissection is necessary. During this early part of the dissection it is important to identify and preserve the posterior and anterior vagal divisions. The short gastric vessels are divided starting from a point midway along the greater curvature of the stomach, all the way to the angle of His (Fig 4).

Heller Myotomy

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Heller myotomy. The fat pad is removed to expose the gastroesophageal junction. A Babcock clamp is then applied over the junction, and traction is applied downward and to the patient’s left to expose the right side of the esophageal wall. The myotomy is performed using the hook cautery in the 11 o’clock position. We do reach the submucosal plane in one point, usually about 3 cm above the gastroesophageal junction. Subsequently, the myotomy is extended upward for about 5 cm and downward onto the gastric wall for about 2 cm. Early in a surgeon’s experience with this procedure it is useful to perform intraoperative endoscopy to identify the squamo-columnar junction. After 10 or 15 procedures it becomes easier to identify the transition between esophageal and gastric musculature, and endoscopy can be avoided. If bleeding from the cut muscle edges occurs, it is important to avoid using the cautery as it can cause damage to the esophageal mucosa with a delayed perforation. Gentle pressure with a sponge usually controls the bleeding. In some patients previously treated with intrasphincteric injection of botulinum toxin, fibrosis can develop at the level of the gastroesophageal junction with loss of the normal anatomic planes. In these circumstances, creating the myotomy can be very difficult and there is an increased risk of a mucosal perforation. If a perforation is suspected, water is instilled into the upper abdomen, and air is insufflated through the orogastric tube. Once the esophageal perforation is identified, it can be closed with fine (5-0) absorbable sutures.

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Dor Fundoplication A posterior 220° fundoplication can be used instead of a Dor fundoplication to prevent gastroesophageal reflux.3 While a posterior fundoplication has the theoretical ad-

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vantage of keeping the edges of the myotomy separated and avoiding recurrent dysphagia, an anterior fundoplication avoids the posterior dissection, it covers the exposed esophageal mucosa, and it has been shown to be an effective antireflux operation.

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The Dor fundoplication is an anterior 180° fundoplication. It is constructed by using two rows of sutures. The first row of sutures is on the left, and comprises three stitches. The uppermost stitch is triangular, and incorporates the gastric fundus, the left side of the esophageal wall (avoiding the anterior vagus nerve) and the left pillar of the crus.

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The second and the third stitches incorporate the esophageal and the gastric wall only.

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The stomach is then folded over the exposed mucosa so that the greater curvature of the stomach lies next to the right pillar of the crus. The uppermost stitch is triangular and includes the gastric fundus, the right side of the esophageal wall and the right pillar of the crus.

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The second and the third stitches are placed between the greater curvature of the stomach and the right side of the esophageal wall. Finally, two or three additional stitches are placed between the gastric fundus and the rim of the esophageal hiatus (without incorporating the esophageal wall) to take any tension away from the right row of sutures.

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Table 1. Laparoscopic Heller Myotomy and Dor Fundoplication Author (year)

Patients, no.

Excellent/Good Results, %

Jamieson (2001) Finley (2001) Zaninotto (2001) Patti (2003) Total

82 91 142 124 439

90 91 98 94 93

POSTOPERATIVE COURSE The orogastric tube is removed at the end of the procedure. A barium swallow is obtained only if a perforation is suspected. Patients are fed the morning of the first postoperative day and are instructed to avoid meat or bread for 2 weeks. About 70% of patients are discharged within 23 hours, and 90% of patients are discharged within 48 hours. Most patients resume their regular activity within 2 weeks.

OUTCOME EVALUATION Table 1 shows the results of the four largest series from centers around the world where this technique is used.6,7,10,11 Overall, excellent or good results are consistently obtained in more than 90% of patients, confirming that a laparoscopic Heller myotomy should be considered today the primary form of treatment for esophageal achalasia.

REFERENCES 1. Patti MG, Pellegrini CA, Horgan S, et al: Minimally invasive surgery for achalasia. An 8 year experience with 168 patients. Ann Surg 587:230, 1999 2. Moonka R, Patti MG, Feo CV, et al: Clinical presentation and evaluation of malignant pseudoachalasia. J Gastrointest Surg 456:3, 1999 3. Champion JK, Delisle N, Hunt T: Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders. Surg Endosc 746:14, 2000 4. Watson DI, Liu JF, Devitt PG, et al: Outcome of laparoscopic anterior 180-degree partial fundoplication for gastroesophageal reflux disease. J Gastrointest Surg 486:4, 2000 5. Zaninotto G, Costantini M, Molena D, et al: Treatment of esophageal achalasia with laparoscopic Helle myotomy and Dor partial anterior fundoplication: Prospective evaluation of 100 consecutive patients. J Gastrointest Surg 282:4, 2000 6. Ackroyd R, Watson DI, Devitt PG, et al: Laparoscopic cardiomyotomy and anterior partial fundoplication for achalasia. Surg Endosc 683:15, 2001 7. Finley RJ, Clifton JC, Stewart KC, et al: Laparoscopic Heller myotomy improves esophageal emptying and the symptoms of achalasia. Arch Surg 892:136, 2001 8. Patti MG, Arcerito M, Feo CV, et al: An analysis of operations for gastroesophageal reflux disease: Identifying the important technical elements. Arch Surg 600:133, 2001 9. Patti MG, Diener U, Molena D: Esophageal achalasia: Preoperative assessment and postoperative follow-up. J Gastrointest Surg 11:5, 2001 10. Zaninotto G, Costantini M, Portale G, et al: Etiology, diagnosis and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg 186:235, 2002 11. Patti MG, Fisichella PM, Perretta S, et al: Impact of minimally invasive surgery on the treatment of esophageal achalasia. A decade of change. J Am Coll Surg 196:698, 2003