Surgical myotomy for achalasia
- Brant K Oelschlager, MD
Brant K Oelschlager, MD
- Professor, Department of Surgery
- University of Washington
- Rebecca P Petersen, MD, MSc
Rebecca P Petersen, MD, MSc
- Assistant Professor, Department of Surgery
- University of Washington
Heller described a surgical approach for the treatment of achalasia in 1913 [1,2]. The Heller myotomy with a fundoplication is the optimal surgical treatment of achalasia, with effective symptom control in 90 to 97 percent of patients [3,4]. The muscle fibers of the lower esophageal sphincter are incised without disrupting the mucosal lining of the esophagus and can be performed as a laparoscopic or open procedure. With the advancement of laparoscopic surgery, the open technique is rarely used.
Alternatively, esophageal and gastric myotomy can be accomplished endoscopically with the per oral endoscopic myotomy (POEM) procedure at select centers as an alternative to Heller myotomy. (See "Peroral endoscopic myotomy (POEM)".)
The indications for surgery, surgical technical insights, and postoperative results of the Heller myotomy will be reviewed here. The pathophysiology and etiology, clinical manifestations and diagnosis, and medical treatment of achalasia, and details of the POEM procedure, are discussed elsewhere. (See "Overview of the treatment of achalasia" and "Pathophysiology and etiology of achalasia" and "Achalasia: Pathogenesis, clinical manifestations, and diagnosis" and "Pneumatic dilation and botulinum toxin injection for achalasia" and "Peroral endoscopic myotomy (POEM)".)
PATIENT SELECTION CRITERIA
The key component for selecting appropriate patients for surgical management is to differentiate achalasia from other motility disorders and from pseudoachalasia, malignancy, and mechanical obstruction. The preoperative evaluation by the surgeon includes a history of patient symptoms as well as a review of previous studies and the results of medical therapies to alleviate symptoms. As an example, patients who are older than 50 years, with symptoms less than six months duration, and/or who have lost more than 10 pounds (4.5 kg) must be evaluated for esophageal cancer.
Pertinent details of the preoperative assessment include:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- PATIENT SELECTION CRITERIA
- REVIEW OF DIAGNOSTIC EVALUATION
- SURGICAL MYOTOMY
- Laparoscopic technique
- - Patient position
- - Abdominal access and port placement
- - Mobilization of the gastric fundus
- - Mobilization of the mediastinal esophagus
- - Myotomy
- - Fundoplication
- Open technique
- Intraoperative technical risks
- OPERATIVE CONSIDERATIONS
- Extended gastric myotomy
- Addition of a fundoplication
- Sigmoid megaesophagus
- Alternatives to laparoscopic or open surgical myotomy
- - Robotic surgery
- - Peroral endoscopic myotomy (POEM)
- POSTOPERATIVE MANAGEMENT
- POSTOPERATIVE COMPLICATIONS
- Recurrent dysphagia
- Gastroesophageal reflux
- Other complications
- RISK OF ESOPHAGEAL CANCER
- SUMMARY AND RECOMMENDATIONS