Principles of Heller's Myotomy
Heller myotomy is a surgical procedure that divides the circular and longitudinal muscle layers of the lower esophageal sphincter to relieve esophagogastric junction outflow obstruction in achalasia, requiring precise myotomy extent (6-7 cm proximal to the gastroesophageal junction and 1.5-2 cm onto the gastric fundus) combined with fundoplication to prevent postoperative reflux. 1, 2
Surgical Isolation and Exposure
The esophagogastric junction must be surgically isolated before performing the myotomy, which requires:
- Division of the phrenoesophageal ligament 1
- Division of short gastric vessels 1
- Complete mobilization to accurately identify the gastroesophageal junction 1
This dissection disrupts important anti-reflux mechanisms that maintain the angle of His, making concomitant fundoplication necessary 1.
Myotomy Technique and Extent
The myotomy must divide both longitudinal and circular muscle layers with specific anatomic landmarks 2:
- Proximal extent: 6-7 cm above the gastroesophageal junction 2, 3
- Distal extent: 1.5-2 cm onto the gastric fundus 2, 4
Technical Refinements
Inject 0.9% NaCl into the muscularis and submucosa before myotomy to facilitate separation of the submucosal layer from the mucosa 2. This hydrodissection technique reduces the risk of mucosal perforation.
The most critical technical pitfall is incomplete myotomy at the distal fundic site, which leads to persistent or recurrent symptoms 2. The myotomy must extend adequately onto the gastric cardia to ensure complete relief of the sphincter mechanism 2, 4.
Fundoplication Requirements
A fundoplication is typically performed in conjunction with laparoscopic Heller myotomy because the surgical dissection disrupts natural anti-reflux barriers 1. Two approaches are used:
- Dor fundoplication (anterior 180-degree): Sutured in a two-rowed manner into both sides of the myotomy 2, 5
- Toupet fundoplication (posterior): Associated with less postoperative dysphagia and heartburn compared to Dor 5
The fundoplication serves dual purposes: preventing reflux and buttressing the myotomy site 4.
Intraoperative Verification
Intraoperative endoscopy should be performed to detect occult mucosal perforations, which occur in approximately 7% of cases 2, 4. These perforations must be identified and repaired immediately to prevent postoperative complications 2.
Postoperative Reflux Management
Gastroesophageal reflux disease affects up to 58% of patients post-myotomy, making acid suppression essential 6. Management includes:
- 8 weeks of proton pump inhibitor therapy to promote mucosal healing 7, 8
- Consider indefinite PPI therapy given the high reflux rate 6, 8
- Erosive esophagitis develops in 23-48% of cases without adequate acid suppression 6
Clinical Outcomes and Follow-Up
Laparoscopic Heller myotomy provides durable symptom relief with 95% of patients experiencing symptoms less than once per week at mean follow-up of 31 months 4. Long-term data shows:
- Freedom from any reintervention is 75% at 10 years 9
- Freedom from esophagectomy is 96.8% at 10 years 9
- Patient satisfaction remains very high with 86% rating outcomes as satisfying or better 4
Follow-Up Algorithm
Initial annual follow-up is essential as the risk of reintervention is greatest during the first year 9. After 3 years of stable symptom relief and esophageal emptying, the follow-up interval may be increased to every 3 years 9.
Common Pitfalls to Avoid
- Incomplete distal myotomy onto the fundus is the most common technical error leading to treatment failure 2
- Unrecognized mucosal perforation can cause serious postoperative complications if not detected intraoperatively 2
- Inadequate postoperative acid suppression leads to erosive esophagitis in nearly half of patients 6
- Postoperative vomiting can disrupt the myotomy repair site and displace the fundoplication, requiring aggressive antiemetic therapy with 5-HT3 receptor antagonists plus dexamethasone 6