INDICATIONS AND EVALUATION
Laparoscopic Heller myotomy is indicated for individuals with well-documented achalasia. This procedure may also be used in association with diverticulectomy for patients with epiphrenic diverticula, and for hypertensive lower esophageal sphincter (LES). The preoperative evaluation of the patient with achalasia includes a barium swallow, esophageal motility study, and upper endoscopy. For atypical presentations, a CT scan is often added to rule out extrinsic compression of the distal esophagus by tumor, aortic aneurysm, or pancreatic pseudocyst. These entities may mimic the endoscopic and radiologic findings of achalasia and are therefore called pseudoachalasia. A Nissen fundoplication that is too tight can create pseudoachalasia as well.
Although Heller myotomy is established as the optimal primary therapy for individuals with achalasia, forceful pneumatic dilatation with balloons measuring 30 to 40 mm in diameter is an acceptable option for those averse to surgical intervention. These patients must be aware that esophageal perforation may result from balloon dilatation, requiring emergency operation. Botulinum toxin injection into the LES may be indicated in patients who are an extraordinarily high risk for Heller myotomy. In addition, in patients when the diagnosis of achalasia is unclear, clinical responsiveness to injection of botulinum toxin usually predicts a good response to Heller myotomy. Peroral endoscopic myotomy (POEM), as described in chapter 18, is also an option, particularly valuable in individuals who have had open upper abdominal surgery, previously, and those patients with type 3 (spastic) achalasia.
Before performing Heller myotomy, the diagnosis must be confirmed. In addition, it is important to try to empty the esophagus of solid food. In patients with a normal esophageal diameter, this may only mean overnight fasting. In individuals with a very large, tortuous esophagus, this may require a liquid diet for 4 to 5 days preoperatively, and even this may not be successful. Additionally, in patients undergoing diverticulectomy we have found it wise to endoscope the patient the day before surgery to make sure the diverticulum is emptied of food. If it is full of food, it can generally be lavaged with vigorous irrigation and suction. Failure to take this extra precaution may give the surgeon the uneasy sensation of stapling across lettuce or other foodstuff at the time of diverticulectomy. Clearly this is not desirable.
General anesthesia with endotracheal intubation is necessary for this operation. Complete neuromuscular blockade is required. A first-generation cephalosporin is administered, although entry into the GI tract is rare. A Foley catheter and an orogastric tube are placed after the induction of anesthesia. The upper abdomen is shaved with clippers, and the abdomen is sterilely prepped and draped. Before the patient emerges from anesthesia, it is important that they be aggressively treated for postoperative nausea with ondansetron and phenergan or its equivalent. Some anesthesiologists also add low doses of steroids for their antiemetic effects. Last, if ...