What are the complications of Heller myotomy if a patient tries to vomit?

Complications of Heller Myotomy When Patient Vomits

Vomiting after Heller myotomy poses significant risk for anastomotic disruption, fundoplication failure, and aspiration pneumonia, requiring immediate assessment and aggressive antiemetic management to prevent these potentially serious complications.

Immediate Risks from Vomiting Post-Myotomy

Mechanical Disruption

• Increased intra-abdominal pressure from vomiting can disrupt the surgical repair site, particularly at the myotomy line where the esophageal muscle has been divided 1
• The fundoplication (typically Dor or Toupet) performed alongside Heller myotomy can become displaced or fail when subjected to forceful retching 1
• Mucosal perforation risk is elevated, especially if there was an inadvertent mucosotomy during the original procedure that was repaired 1

Aspiration Risk

• Patients with achalasia have an aperistaltic esophagus that cannot effectively clear regurgitated material 1
• Aspiration pneumonia occurs in up to 20% of patients unable to protect their airways, particularly those with neurological complications 1
• The risk is compounded post-myotomy because the lower esophageal sphincter has been intentionally weakened 1

Specific Post-Myotomy Complications

Fundoplication-Related Issues

• Obstructing fundoplication can develop in 27% of patients requiring revision, manifesting as recurrent dysphagia and vomiting 2
• Forceful vomiting may cause the fundoplication wrap to slip or become too tight, creating obstruction 2
• This is particularly problematic given the aperistaltic esophagus cannot overcome even mild obstruction 1

Periesophageal Complications

• Periesophageal and perihiatal fibrosis occurs in 27% of revision cases, which can be exacerbated by inflammation from repeated vomiting 2
• Scarring around the myotomy site may worsen with each episode of forceful retching 3, 2

Reflux-Related Sequelae

• Gastroesophageal reflux disease affects up to 58% of patients post-myotomy, and vomiting worsens acid exposure 1
• Erosive esophagitis develops in 23-48% of cases, which can progress to stricture formation if combined with recurrent vomiting 1
• Barrett's esophagus has been documented in patients with persistent reflux post-myotomy 1

Management Approach

Immediate Antiemetic Strategy

• Administer 5-HT3 receptor antagonists (ondansetron) plus dexamethasone as first-line therapy for postoperative nausea and vomiting 4
• Use multimodal approach targeting different receptors if initial therapy fails 4
• Avoid anticholinergics and high-dose phenothiazines as they cause sedation that impairs neurological monitoring 4

Hydration and Supportive Care

• Maintain euvolemia with adequate hydration as dehydration is a common cause of persistent vomiting 1, 4
• Consume ≥1.5 L liquids daily, increasing intake as needed 1
• Monitor and correct electrolyte abnormalities that can perpetuate vomiting 4

Analgesic Optimization

• Reduce or eliminate opioid analgesics which significantly worsen nausea and vomiting 4
• Consider NSAIDs or acetaminophen as alternatives if not contraindicated 4

When to Escalate Care

Red Flag Symptoms Requiring Urgent Imaging

• Obtain urgent CT or upper GI contrast study if vomiting is accompanied by:
  • Worsening or severe chest/abdominal pain 5, 4
  • Fever or tachycardia suggesting perforation or leak 5
  • New dysphagia worse than baseline 2
  • Subcutaneous emphysema 5

Surgical Complications to Consider

• Perforation or leak at the myotomy site requires immediate surgical consultation 1, 6
• Leaks can occur after discharge and may require transthoracic catheter drainage, parenteral nutrition, or endoscopic stenting 6
• Incomplete myotomy (20% of revision cases) or progression of disease (22%) may present with persistent vomiting 2

Prevention Strategies

Dietary Modifications

• Maintain liquid diet for 24 hours before any procedure to minimize gastric contents 5
• Progress slowly through diet stages post-myotomy: clear liquids, then full liquids for 5-7 days, then small frequent meals of low-fiber, low-fat foods 5
• Instruct patients to eat slowly, chew thoroughly (≥15 chews per bite), and avoid dry foods that can trigger dysphagia and subsequent vomiting 1

Medication Management

• Prescribe 8 weeks of proton pump inhibitor therapy to reduce acid secretion and promote healing 5
• Consider lifelong PPI therapy given the high reflux rate post-myotomy 1
• When vomiting persists >2-3 weeks, add thiamin supplementation to prevent neurological complications 1

Common Pitfalls to Avoid

• Do not dismiss persistent vomiting as "normal postoperative course" - it may indicate surgical complications requiring revision in 10-20% of cases 3, 2
• Avoid assuming all post-myotomy dysphagia is from incomplete myotomy - obstructing fundoplication and periesophageal fibrosis are equally common causes 2
• Do not delay imaging in patients with persistent symptoms - complications like leaks are unpredictable and can occur after discharge 6
• The perception of dysphagia may persist even after successful revision surgery in a significant minority of patients 2