What are the steps involved in a Heller myotomy (esophageal lengthening procedure)?

From the Guidelines

Heller myotomy is a surgical procedure that can be effectively performed using the per-oral endoscopic myotomy (POEM) technique, which has been shown to be a safe and effective management option for achalasia, with a reported success rate of >90% 1. The procedure involves several key steps, including making a mucosal incision 10–15 cm proximal to the lower esophageal sphincter (LES) and creating a submucosal tunnel, followed by a circular muscle myotomy from within the submucosal tunnel, beginning at least 2–3 cm distal to the mucosotomy and progressing to the distal point of cardia dissection 1. Some of the key considerations for the procedure include:

• The use of a standard endoscope and electrocautery to perform the myotomy
• The importance of avoiding abdominal incisions and minimizing the risk of vagal nerve injury and intra-abdominal adhesions
• The potential for a longer myotomy if desired, without the need for mediastinal dissection
• The need for careful patient selection and consideration of the potential risks and benefits of the procedure, including the risk of gastroesophageal reflux disease (GERD) 2. The POEM procedure has been shown to be more effective than laparoscopic Heller myotomy (LHM) in relieving dysphagia in the short term, but is associated with a higher incidence of pathologic reflux 1. Overall, the POEM procedure is a viable option for the treatment of achalasia, and its use should be considered on a case-by-case basis, taking into account the individual patient's needs and preferences, as well as the available evidence and expert recommendations 2.

From the Research

Heller Myotomy Steps

The steps involved in a Heller myotomy are not explicitly outlined in the provided studies. However, the following information can be gathered:

• Laparoscopic Heller myotomy is a surgical procedure used to treat achalasia, a motility disorder of the esophagus 3, 4, 5.
• The procedure involves making an incision in the lower esophageal sphincter to relieve symptoms of dysphagia and regurgitation 3, 4, 5.
• Peroral endoscopic myotomy (POEM) is an alternative procedure that can be used to treat achalasia, and it involves making an incision in the esophageal mucosa to access the lower esophageal sphincter 6, 3, 4, 5, 7.
• The choice of procedure depends on various factors, including patient goals and the presence of any complications 5.
• Anesthetic considerations are important for both procedures, and general anesthesia is often recommended for POEM 6, 7.

Comparison of Heller Myotomy and POEM

Some key differences between Heller myotomy and POEM include:

• Efficacy: POEM may be more effective in relieving dysphagia, but it is associated with a higher risk of gastroesophageal reflux disease (GERD) 3.
• Complications: POEM is associated with a higher risk of adverse events, including infectious complications, gastrointestinal bleeding, and thoracic adverse events 4.
• Length of stay and costs: The length of stay and costs associated with both procedures are similar 4.
• Patient outcomes: Quality of life appears to be similar after both procedures, but POEM may be associated with lower rates of perforation, leak, dysphagia, and reintervention 5.