Esophageal Myotomy

Preparation

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Preoperative Workup:

• High-Resolution Manometry (HRM):
  • Gold standard for diagnosis
  • Determines LES relaxation and esophageal peristalsis
• Barium Swallow:
  • Assesses anatomy, dilation, emptying, tortuosity, and diverticula
• Upper Endoscopy (EGD):
  • Rules out pseudoachalasia, esophagitis, malignancy, food stasis
• Chest CT (if needed):
  • Used for large diverticula, tumors, or megaesophagus

Diet and Fasting:

• Clear liquids for 1–3 days pre-op
• NPO 8–12 hours before procedure
• In achalasia with retention, pre-endoscopy for lavage may be done

Medication Review:

• Discontinue anticoagulants and antiplatelets per protocol
• Adjust medications for hypertension, seizures, diabetes

Other Measures:

• Anesthesia evaluation
• Blood tests, ECG, chest X-ray
• Pulmonary function tests (if thoracic approach planned)
• Treat active esophagitis or candidiasis
• Smoking cessation
• Post-op support planning

Patient Positioning

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Based on approach:

• Laparoscopic Heller Myotomy:
  • Supine or modified lithotomy
  • Reverse Trendelenburg
  • Arms at sides or on boards
• Thoracoscopic Approach:
  • Left thoracoscopy: Right lateral decubitus
  • Right thoracoscopy: Left lateral or prone position
  • Table flexed to widen intercostal spaces
• POEM (Peroral Endoscopic Myotomy):
  • Supine with or without shoulder elevation
  • Left lateral position possible
  • General anesthesia with endotracheal intubation

All positions require careful padding and stabilization.

Surgical Approach

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1. Laparoscopic Heller Myotomy:

• Most common for achalasia
• 5 ports placed in upper abdomen
• Pneumoperitoneum created
• Liver retracted for hiatus access

2. Thoracoscopic Myotomy:

• Ports in chest; lung deflated
• Used for longer or proximal myotomy
• Right side preferred for upper/mid esophagus
• Less common than laparoscopy

3. POEM:

• Endoscopic, incisionless
• Mucosal incision and submucosal tunnel
• Myotomy through tunnel into stomach
• Mucosal entry closed with clips

Choice depends on disease, anatomy, previous surgeries, and operator expertise.

Intraoperative Steps

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Laparoscopic Heller Myotomy

• Ports placed, liver retracted
• Dissection of GEJ and hiatus
• Myotomy: 5–7 cm above GEJ + 1.5–3 cm into cardia
• Mucosa inspected (air/dye leak test)
• Repair any perforation
• Partial fundoplication performed (see below)

Thoracoscopic Myotomy

• Ports placed; single-lung ventilation
• Mobilize esophagus, preserve vagus nerves
• Longitudinal myotomy done
• Mucosal integrity checked
• Antireflux procedure optional/difficult
• Chest tube placed; lung re-inflated

POEM

• Mucosal incision (~10–15 cm above GEJ)
• Submucosal tunnel created to stomach
• Circular muscle fibers incised
• Closure of mucosal entry with clips
• Leak check via contrast swallow

Length and depth of myotomy adjusted to disorder type.

Reconstruction

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After Heller Myotomy

Fundoplication (antireflux):

• Dor (anterior, 180–200°):
  • Fundus covers anterior myotomy
  • Sutured to esophageal muscle and diaphragm
  • Preferred for mucosal protection and reflux control
• Toupet (posterior, 270°):
  • Fundus wraps behind esophagus
  • More extensive, may risk dysphagia
• Nissen (360°):
  • Avoided due to high dysphagia risk

After POEM

• No standard fundoplication
• Higher GERD risk post-POEM
• Managed with PPIs
• Endoscopic reflux procedures under study

Goal: Prevent GERD while avoiding postoperative dysphagia.

Possible Complications and Management

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General:

• Bleeding: Controlled intraoperatively; transfusion rarely needed
• Infection: Pneumonia, wound infection, mediastinitis
• Anesthesia risks

Heller Myotomy Specific:

• Mucosal Perforation: Most common; repaired and covered with fundoplication
• Pneumothorax (laparoscopic): Requires decompression
• Organ Injury: Spleen, vagus nerve, lung
• Port Site Hernia, Adhesions
• Chronic pain (thoracotomy)

POEM Specific:

• Gas-related events: Subcutaneous emphysema, pneumoperitoneum—usually self-limiting
• Mucosal injury or leak: Clipped endoscopically
• Submucosal bleeding: Managed endoscopically
• Esophagitis, pleural effusion

Late Complications:

• GERD:
  • Common after POEM (20–50%), less after Heller with fundoplication
  • Treated with PPIs
• Recurrent Dysphagia:
  • From incomplete myotomy, fibrosis, tight wrap
  • Managed by dilation, repeat myotomy, botox, or esophagectomy
• Barrett’s or Cancer:
  • Surveillance recommended

Long-Term Care:

• Follow-up for symptom monitoring
• Diet modification
• Endoscopic surveillance in high-risk cases