Heller myotomy

Heller myotomy is a surgical procedure that is done for the treatment of a condition called achalasia.

Achalasia is a disorder of the oesophagus (food pipe) that causes difficulty in swallowing. The oesophagus is a muscular tube that carries liquid and food from the throat to the stomach. The lower end of the oesophagus that connects to the stomach is guarded by a ring-like muscle called the sphincter. This sphincter prevents the backflow of food from the stomach to the oesophagus. Normally, when you swallow food, this sphincter relaxes to allow the food to pass into the stomach. However, in individuals with achalasia, this sphincter does not open properly. Hence, the food gets stuck in the oesophagus, and often comes back to the mouth. This difficulty in swallowing is usually resolved after taking small sips of water. 

The exact reason for the condition is not known; however, damage to the nerve cells in the sphincter muscles can be a reason. 

Heller myotomy helps to improve swallowing in individuals with achalasia by cutting the muscle fibres of the lower oesophageal sphincter.

The name Heller myotomy comes from the fact that it was first performed by Ernest Heller in the year 1913, while a myotomy is any procedure which involves cutting of a muscle.

Your surgeon will recommend this surgery if you show the following symptoms of achalasia:

• Difficulty swallowing liquid and food
• Chest pain
• Drooling of saliva or vomiting
• Frequent chest infections
• Significant weight loss over a period of time
• Heartburn
• Coughing and choking

Although not every individual will show symptoms of achalasia, symptoms such as swallowing difficulty can develop over a period of about two years. If left untreated, achalasia can develop into oesophageal cancer.

The following tests may be performed to confirm achalasia:

• Oesophageal manometry study: A test performed by inserting a small tube through your nose down the throat to measure the pressure in the lower oesophageal sphincter and oesophagus.
• Barium swallow test: A special type of X-ray that allows the doctor to observe the oesophagus when you swallow.
• Diagnostic gastroscopy: A test performed by inserting a long tube through the mouth to look at your oesophagus.

A doctor may not recommend this surgery in individuals with the following conditions as they can increase the risks of surgery:

• Lung diseases, heart diseases, or kidney diseases
• Pregnancy 
• Smoking habit Read more: Harmful effects of smoking on health

You may need the following preparations before the surgery:

• The surgeon may discuss the following with you before the surgery:
  • The medicines you take, including non-prescription medications and herbs
  • Whether you are pregnant
  • Whether to discontinue blood-thinning medicines such as ibuprofen, aspirin, and warfarin
  • Stopping smoking
  • Drugs that you can take on the day of the surgery
• Avoid eating or drinking anything from the midnight before the surgery to prevent the following under the effect of anaesthesia:
  • Vomiting
  • The entry of food into the lungs
• While going to the hospital for the surgery, take care of the following:
  • Wear loose, comfortable clothes
  • Do not wear any jewellery, makeup, nail polish or dentures
  • Ask a responsible adult to drive you home after the surgery

After arriving at the hospital, the hospital staff will ask you to change into a hospital gown, and you will be taken to the operating room. Your blood pressure, heart rate, and oxygen levels will be continuously monitored during the procedure. An intravenous (IV) line will be placed in your hand. The types of anaesthesia that may be used during the surgery include:

• General anaesthesia: Makes you fall asleep during the procedure. General anaesthesia is usually used during the procedure.
• Regional anaesthesia: Numbs a large part of the body, but keeps you awake. This anaesthesia may be used alone or in combination with general anaesthesia.
• Local anaesthesia: Numbs a small part of the body and keeps you awake. This anaesthesia may be injected around the surgical site to provide pain relief.

Heller myotomy can be performed by two methods, namely open and laparoscopic. Laparoscopic is usually the preferred method since it is associated with minimum pain post-surgery and faster recovery. However, if the procedure cannot be completed by the laparoscopic approach, open surgery will be performed. Open surgery results in a large scar and requires an extended stay in the hospital.

The laparoscopic procedure involves the use of a long thin camera and other tools inserted through tiny cuts on the body. The camera allows the surgeon to view your internal structures on a television. The surgery usually involves the following steps:

• An anesthesiologist will administer anaesthesia to you.
• The surgeon will make about five small incisions on your abdomen, above your belly button.
• He/she will push carbon dioxide gas into your abdomen to inflate it. This will give the surgeon more area to use the surgical instruments and view your organs.
• After accessing the oesophagus, the surgeon will make small cuts in the stiffened sphincter muscle.
• As there is a risk of stomach acid going back up into the oesophagus (acid reflux) after the surgery, the surgeon will perform a fundoplication after this procedure. This includes wrapping the top end of the stomach around the oesophagus like a wrap and fixing it in place with sutures such that it functions like a valve and helps prevent acid reflux.
• If the laparoscopic approach is not viable, open surgery is done that requires a relatively larger vertical incision at or near the midline of the abdomen.

The laparoscopic procedure requires one to two days of hospital stay, while the open procedure requires you to stay in the hospital for about a week. After the surgery, you will be transferred to the recovery room and can expect the following:

• Your vital signs will be closely monitored.
• The medical staff may administer fluids through a drip. 
• The doctor may give you some medicines to provide relief from the pain.
• A special type of X-ray called barium oesophagram may be performed to examine your oesophagus.
• You may be given fluids to drink after you wake up from the surgery. If you are comfortable with drinking liquids, you can start with soft foods from the next day.

The surgeon will recommend the following care at home after a Heller myotomy:

• It may not be easy to swallow food during the initial days after the surgery. Hence, you should chew the food well and eat a small amount of food at a time.
• Take soft food for two weeks after the surgery. Avoid eating bread for six to eight weeks. You will need to permanently exclude fizzy drinks from your diet.
• You may still experience some acid reflux after fundoplication surgery. The surgeon may prescribe some medicines for the same.
• Your oesophagus may take about six to eight months to heal completely. However, you will be able to get back to your daily routine in about six to eight weeks. 
• You will be able to resume driving after three to four days (after a laparoscopic procedure) or about 10 days (after open surgery).

Heller myotomy helps to remove the obstruction in the oesophagus and improves swallowing.

When to see the doctor?

Contact the surgeon if you experience any of the following:

• Increased pain or discomfort
• Nausea and vomiting
• Difficulty emptying the bladder
• Swelling, redness, or drainage at the site
• Fever above 101^°F
• Reopening of the wound
• Diarrhoea
• Constipation

The complications associated with the surgery include:

• Damage to the inner wall of the oesophagus
• Wound infection
• Damage to the spleen or other abdominal organs
• Formation of blood clots in the leg that can spread to the lungs
• Scarring at the surgery site
• Adverse reaction to surgical materials
• Complications of general anaesthesia such as:
  • Lung infection
  • Confusion
  • Drug allergy
  • Heart attack
• Need for another surgery to remove the scar tissue or problems in other muscle fibres

You will have a follow-up visit in about six weeks after the surgery and then at three months for a post-operative assessment.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.