Gastroenterology

Laparoscopic Heller's Cardiomyotomy Treatment

Achalasia Treatment

Achalasia is a condition that causes problems with swallowing. It can also cause regurgitation (bringing food back into your mouth), chest pain and weight loss. Achalasia happens when the cardiac sphincter (the valve that controls how food passes into your stomach) does not relax properly.

Overview

Laparoscopic Cardiomyotomy / Myotomy is a surgery done to the patients who are suffering from achalasia. Laparoscopic Myotomy consists of making 5 small incisions into the patient’s abdominal wall with a scope. The muscle at the lower end of the esophagus is then cut, allowing the passage of food to pass easily into the stomach.

What is laparoscopic Heller Cardiomyotomy?

Achalasia is a functional disorder of the esophagus indicated by the loss of coordinated peristalsis and lack of lower esophageal sphincter (LES) relaxation. Achalasia is occurred due to the absence of the myenteric neural plexus.  Symptoms for Achalasia include dysphagia and chest pain. Achalasia results in the deformity on upper gastrointestinal which is typically called as “bird’s beak”. Upper endoscopy and manometry are usually done in the diagnostic workup, the later indicating a lack of normal peristalsis and incomplete LES relaxation. The treatment for Achalasia includes botulinum, bougie dilation, and laparoscopic Heller myotomy.  Of these, the laparoscopic Heller myotomy offers 77-100% resolution of symptoms at 5 years and up to 75% at 15 years, but it carries a 6.3% risk of complications and 0.1% risk of mortality.  Botulism toxon injection is effective to 85% initially only, but 30% at one year.  Endoscopic dilation if 15-58% effective at 10 years, but may demand multiple dilations. The effect is 13% after the first treatment and carries a risk of perforation of about 1-5.6%.

Laparoscopic Heller myotomy is a minimally invasive method that opens the tight lower esophageal sphincter (the valve between the Page Imageesophagus and the stomach) by performing a myotomy to relieve the dysphagia. Further, a Dor fundoplication (a partial wrapping of the stomach around the esophagus to make a low-pressure valve) is done to prevent reflux from the stomach into the esophagus following the myotomy. There is a very slim chance that patients may develop reflux despite Dor fundoplication and may be required to treat with antacid medication.

Planning for Laparoscopic Myotomy, follow these pieces of advice

• One mustn’t smoke at least 4 weeks prior to their surgery.  

• Do not take any nonsteroidal anti-inflammatory or Aspirin products up to 1 week prior to the surgery date.

• If the patient has a prior heart history, with heart stents, he/she may need to remain on Aspirin.

 • Acetaminophen is fine to take prior to surgery.

 • Any usage of herbal medication by the patient must be informed to the surgeons as it may cause excessive bleeding or other complications at operation.

• Do walk 2-3 miles a day prior to surgery to get in the best shape possible for surgery.

Procedure

Dissecting the esophageal hiatus

A fan, triangle, or other liver retractor elevates the left lobe of the liver to facilitate visualization of the esophageal hiatus. The gastrohepatic ligament is entered followed by dissection of the esophagophrenic ligaments. The anterior vagus nerve is identified and preserved.

Myotomy

The gastroesophageal junction is identified, and this area can be exposed with the help of caudal retraction on the gastroesophageal fat pad.  A monopolar hook cautery or ultrasonic device is used to divide the outer, longitudinal muscle fibers of the esophagus on its right anterolateral surface.  Many surgeons will use concomitant upper endoscopy for visualizing the high-pressure zone during the division of the esophageal muscle layer; under this direct visualization, the circular fibers can be divided. This dissection is taken 2-3 cm onto the stomach carefully; an air leak test can be performed afterword.

Partial fundoplication

An anterior, Dor or posterior, Toupet, fundoplication can be performed as an antireflux procedure following the esophagogastric myotomy. Division of short gastric vessels to facilitate fundoplication can be preferred by the surgeons.

Postoperative care

A gastrograffin study may be performed on a postoperative day, the number one method to rule out a leak and helps in examining the patency of the gastroesophageal junction. The patient may be started on a full liquid or soft diet initially.

What after Laparoscopic Myotomy?

Pain Management

• Most pain can be associated with the gas that was used to inflating the abdomen during surgery; the best way to get rid of this is by walking. Proper pain medication is generally provided by the doctors.

• It is important to drink plenty of water and other fluids to avoid constipation, which can occur often while taking most commonly prescribed pain medications. However, a stool softener is prescribed to help avoid constipation.

Taking care of Incisions

The patient has 5 small incisions on his/her abdomen.

• It is not uncommon for the incision closest to the belly button to have some drainage; one must monitor this drainage if it becomes thick in consistency, or is greenish in color. Contact your doctor regarding the drainage.

• No dressings are needed for the incisions however tight clothes must be avoided around the incision sites or fabrics which may cause irritate the skin.

• Keep the incision clean with soap and water in the shower.

• No tub baths, or soaking the incisions in a pool/hot tub until they are well healed, the healing process generally takes up to 4 weeks.

One must contact his/her doctor when experiencing the following symptoms:

• Body temperature reaches above 101 F

• A Significant amount of discomfort or increase in abdominal pain

• Redness, drainage or swelling in the incision sites

• Opening of incision

• Change in the health status of the patient i.e. the person is experiencing nausea, vomiting, chills, profuse sweating, diarrhea or constipation

• Difficulty in swallowing

Activity Level

 • It is not recommended to lift anything greater than 10 lbs. for a month

• It is not recommended to drive when the patient is taking narcotic pain medicine and especially for 2-3 days after surgery.

• The Patient may experience fatigue; one can build up stamina and strength over time. Walking is the best activity for increasing stamina.

Diet

It will be very important to see a dietitian prior to discharging. The patient will be on a special diet for 2 weeks.

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