From the Guidelines
Heller myotomy is a highly effective treatment for achalasia, providing long-term symptom relief for approximately 85-95% of patients by surgically cutting the lower esophageal sphincter (LES) muscles, allowing food to pass more easily into the stomach. During this minimally invasive procedure, the surgeon makes small incisions in the tight muscle fibers of the LES, reducing the pressure that prevents normal swallowing. Most patients experience significant improvement in swallowing function and reduced symptoms like regurgitation, chest pain, and weight loss. The procedure is typically performed laparoscopically or thoracoscopically and is often combined with a partial fundoplication (like Dor or Toupet) to prevent post-operative acid reflux, which occurs in about 10-20% of patients without this additional step 1.
Key Benefits and Considerations
- The procedure works by addressing the fundamental problem in achalasia - the inability of the LES to relax properly due to degeneration of inhibitory neurons in the myenteric plexus.
- Recovery usually involves a brief hospital stay of 1-2 days, a gradual return to normal diet over 1-2 weeks, and avoiding heavy lifting for about 6 weeks.
- Gastroesophageal reflux disease is frequent and often severe after Heller myotomy, as shown by studies 1, and routine chronic high-dose proton pump inhibitor therapy is recommended to improve long-term success.
- Prior endoscopic therapy (PD or Botox) has been blamed for increased operative complications and higher rate of HM failure, but other studies have found that preoperative PD or Botox did not correlate with fibrosis in esophageal muscle biopsies or therapeutic outcome 1.
Comparison with Other Treatments
- Per-oral endoscopic myotomy (POEM) is a newer procedure that has been compared to Heller myotomy, with some studies suggesting that POEM may be more effective in relieving dysphagia in the short term, but with a higher incidence of pathologic reflux 1.
- The choice between Heller myotomy and POEM should be based on individual patient factors and the expertise of the treating physician, with consideration of the potential benefits and risks of each procedure.
From the Research
Effects of Heller Myotomy on Achalasia
- Heller myotomy is a surgical procedure that has been shown to provide long-term symptom relief and patient satisfaction for patients with achalasia 2.
- The procedure involves cutting the muscles of the lower esophageal sphincter to allow for easier swallowing, and can be performed laparoscopically or robotically.
- Studies have reported significant improvements in symptoms such as dysphagia, regurgitation, and chest pain after Heller myotomy 2, 3, 4.
- The addition of fundoplication to the procedure has been shown to reduce the risk of gastroesophageal reflux disease (GERD) 2, 5.
- Patient factors such as age, comorbidities, and type of achalasia should be taken into account when choosing a treatment, and shared decision making is important in deciding on the best course of treatment 6.
Comparison to Other Treatments
- Heller myotomy has been compared to other treatments for achalasia, including pneumatic dilation and peroral endoscopic myotomy (POEM) 6, 5.
- While POEM has been shown to be effective in the short-term, Heller myotomy has been found to have similar long-term outcomes with a lower risk of GERD 5.
- Robot-assisted Heller myotomy has been shown to have similar outcomes to traditional laparoscopic Heller myotomy, with a decreased risk of mucosal injury and shorter hospital stay 4.
Long-Term Outcomes
- Long-term follow-up studies have reported durable relief of dysphagia and high patient satisfaction after Heller myotomy 2, 4.
- However, some patients may experience reflux symptoms, which can be controlled with medical acid suppression 4.
- Further research is needed to determine the best treatment approach for individual patients and to compare the long-term outcomes of different treatments 5.