From the Guidelines
A Heller myotomy is a highly effective surgical procedure for treating achalasia, with immediate improvement in swallowing ability, but it carries a significant risk of gastroesophageal reflux disease (GERD), which can be mitigated with routine chronic high-dose proton pump inhibitor therapy and partial fundoplication. The procedure involves cutting the muscle fibers of the lower esophageal sphincter (LES) to reduce pressure and allow food to pass more easily. According to a recent study 1, laparoscopic myotomy with partial fundoplication (LHM) has been demonstrated to be safe and effective in multiple studies, with excellent outcomes in high-level randomized controlled trials (RCTs).
Post-Operative Care and Outcomes
After a Heller myotomy, patients typically follow a gradual progression from a liquid diet to soft foods and then regular foods over 2-4 weeks. Some discomfort at the surgical site is normal and can be managed with prescribed pain medications like acetaminophen or, occasionally, stronger medications for the first few days. The study 1 highlights the importance of considering patient and disease characteristics, patient preferences, and local expertise when deciding among treatment modalities for achalasia.
Potential Side Effects and Complications
Potential side effects include gastroesophageal reflux disease (GERD), which occurs in about 20-30% of patients because the procedure reduces the barrier that prevents stomach acid from flowing back into the esophagus. As noted in an earlier study 1, prior endoscopic therapy does not correlate with fibrosis in esophageal muscle biopsies or therapeutic outcome, but the risk of GERD is significant. To minimize this risk, surgeons often perform a partial fundoplication during the same operation.
Return to Normal Activities
Most patients can return to normal activities within 2-3 weeks, though heavy lifting should be avoided for about 6 weeks. The procedure works by physically disrupting the tight muscle fibers that prevent normal relaxation of the LES, effectively creating a controlled opening that allows food passage while maintaining enough function to limit severe reflux. The recent study 1 provides guidance on the preferred treatment for type III achalasia, suggesting that per-oral endoscopic myotomy (POEM) should be considered the preferred treatment, but for other types, the decision among treatment modalities should be based on shared decision making.
From the Research
Effects of Heller Myotomy
The effects of having a Heller myotomy, an esophageal surgical procedure, can be understood through various studies that have examined its outcomes.
- The procedure has been shown to provide significant improvement in symptoms of achalasia, including dysphagia, regurgitation, and chest pain 2, 3, 4, 5, 6.
- Studies have demonstrated that laparoscopic Heller myotomy can be safely undertaken, with low rates of complications and high patient satisfaction 2, 3, 4, 5, 6.
- The procedure has been compared to open Heller myotomy, with findings suggesting that the laparoscopic approach causes less early detriment to quality of life and has comparable success rates 2.
- Some studies have reported that patients who undergo Heller myotomy after failed endoscopic interventions, such as botulinum toxin injections or pneumatic dilation, may have slightly worse outcomes compared to those who undergo the procedure as first-line therapy 6.
- However, other studies have found that laparoscopic Heller myotomy can still provide durable relief from achalasia and salvage failures after other treatments 3, 4.
Symptom Improvement
Symptom improvement after Heller myotomy has been consistently reported across studies.
- Dysphagia, a primary symptom of achalasia, has been shown to improve significantly after the procedure, with many patients experiencing complete resolution of symptoms 2, 3, 4, 5, 6.
- Regurgitation and retrosternal pain have also been found to decrease significantly after Heller myotomy 5.
- Weight loss, a common consequence of achalasia, has been reported to improve after the procedure 5.
Complications and Safety
The safety profile of Heller myotomy has been evaluated in several studies.
- Complications, such as mucosal perforation, spleen injury, and trocar-site infection, have been reported, but are relatively rare 3.
- Esophageal leaks have been found to be uncommon after the procedure 3.
- Reflux, a potential complication of Heller myotomy, has been reported to occur in some patients, but can often be managed with proton pump inhibitors 3, 5.