From the Guidelines
A Heller myotomy is a surgical procedure performed to treat achalasia by cutting the muscle fibers of the lower esophageal sphincter (LES), effectively weakening it and allowing food and liquids to pass more easily into the stomach. The primary purpose of this procedure is to alleviate the symptoms of achalasia, such as difficulty swallowing, regurgitation, chest pain, and weight loss, by addressing the mechanical problem of the tight sphincter directly. According to the study by Kahrilas et al. 1, laparoscopic Heller myotomy (LHM) is a robust therapy currently available for achalasia, and its role remains relevant despite the emergence of per-oral endoscopic myotomy (POEM).
The procedure is typically performed laparoscopically or robotically through small incisions in the abdomen, though traditional open surgery is sometimes used. A Heller myotomy is often combined with a partial fundoplication (wrapping part of the stomach around the lower esophagus) to prevent gastroesophageal reflux, which can occur after the sphincter is weakened. As outlined in the study by the AGA institute 1, the choice of treatment for achalasia should be based on patient-specific parameters, including Chicago Classification subtype, comorbidities, and disease phenotype.
Some key points to consider when evaluating the purpose of a Heller myotomy include:
- The procedure is effective in treating achalasia by weakening the LES and allowing food to pass more easily into the stomach 1.
- A Heller myotomy can be performed laparoscopically or robotically, and is often combined with a partial fundoplication to prevent gastroesophageal reflux 1.
- The choice of treatment for achalasia should be based on patient-specific parameters, including disease phenotype and comorbidities 1.
- POEM is a minimally invasive technique that can be considered as a treatment option for achalasia, particularly for type III achalasia, but its long-term outcomes data are limited 1.
Overall, the primary purpose of a Heller myotomy is to treat achalasia by weakening the LES and alleviating symptoms, and it remains a relevant treatment option despite the emergence of POEM.
From the Research
Purpose of Heller Myotomy
The purpose of a Heller myotomy is to relieve symptoms of achalasia, a rare esophageal motility disorder, by reducing esophageal outflow resistance. This is achieved by disrupting the muscles at the level of the esophagogastric junction to allow esophageal emptying by gravity 2.
Key Aspects of the Procedure
- The procedure involves a long esophageal cardiomyotomy extending at least 2 cm onto the gastric cardia, with a concomitant fundoplication 3.
- A partial fundoplication is necessary to control gastroesophageal reflux, as reflux of gastric contents into the aperistaltic esophagus can cause esophagitis, peptic strictures, Barrett's esophagus, and even esophageal carcinoma 2.
- The choice of partial fundoplication is based on surgeons' preference and expertise, with options including Dor, Toupet, and Nissen fundoplications 4.
Outcomes and Efficacy
- Laparoscopic Heller myotomy has comparable success to open Heller myotomy, and causes less early detriment to quality of life 3.
- The procedure is effective in relieving symptoms, with dysphagia resolving in the majority of patients, even when the esophagus is massively dilated 5.
- Key steps in the surgical approach include extensive esophageal mobilization, division of the short gastric vessels, mobilization of the anterior vagus nerve, an extended gastric myotomy, and a Toupet partial fundoplication 6.