Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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228 Section III • The Esophagus

STEP 4: POSTOPERATIVE CARE

◆ After recovery from anesthesia, the patient can be taken to a ﬂ oor bed.

◆ The patient should be encouraged to ambulate as early as postoperative day 1. Incentive

spirometry and good pulmonary physiotherapy are essential.

◆ The nasogastric tube may be removed on the second postoperative day, and jejunostomy

tube feedings are started. Sips of clear liquids may be allowed when bowel function normal-

izes. Between postoperative days 5 and 7, a barium swallow should be performed to evalu-

ate the anastomosis. If the anastomosis is intact, a soft diet is started. As diet is advanced,

bulky food and carbonated beverages should be avoided.

STEP 5: PEARLS AND PITFALLS

◆ When using a jejunal graft, one should be prepared to substitute a colonic graft if the jeju-

num is inadequate, either because the length is insufﬁ cient to replace the full length of the

esophagus or because the blood supply is damaged during harvesting.

◆ Studies comparing the quality of life of patients after esophagectomy with age-matched con-

trols demonstrated no signiﬁ cant differences in outcomes between the populations.

SELECTED REFERENCES

1. Meneshian A, Heitmiller RF: Surgical management of esophageal cancer. In Yuh D (ed): Johns Hopkins

Manual of Cardiothoracic Surgery. New York, McGraw-Hill, 2007, pp 273-294.

2. Deschamps C, Nichols FC III, Cassivi SD, et al: Long-term function and quality of life after esophageal

resection for cancer and Barrett’s. Surg Clin North Am 2005;85:649-656.

3. Linden PA, Swanson SJ: Esophageal resection and replacement. In Sellke F (ed): Sabiston & Spencer:

Surgery of the Chest. Philadelphia, Elsevier, 2005, pp 627-651.

229

STEP 1: SURGICAL ANATOMY

◆ A comprehensive understanding of the anatomy of the thorax and esophagus is critical

before undertaking surgical procedures on the esophagus.

◆ Figure 19-1, A, demonstrates key anatomic structures that must be considered in an open

Heller myotomy.

Anterior vagus nerve

Stenotic distal

esophagus

Incision

FIGURE 19 –1

CHAPTER

Open Heller Myotomy

David B. Loran and Joseph B. Zwischenberger

230 Section III • The Esophagus

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ The word achalasia means “failure to relax,” which characterizes the pathophysiologic

dysfunction of the lower esophageal sphincter in this disease. The sustained high-pressure

zone is believed to be due to denervation or dysfunction of the nerves in Auerbach’s plexus,

which leads to the loss of inhibitory effects of these ganglia on the muscles of the lower

esophageal sphincter. Initiation of swallowing is normal; however, the esophagus cannot

empty properly, which leads to varying degrees of dysphagia. Typical symptoms include

odynophagia, foul breath, regurgitation of undigested food, and the patient describing a

sensation of food “getting stuck” in his or her lower chest. Late symptoms result from the

sequelae of continued aspiration and include hoarseness, pneumonitis, pneumonia, and

lung abscess.

◆ Diagnosis is based on patient symptoms and objective testing. Barium esophagram will

show a mild to severely dilated esophageal body with a characteristically smooth “bird-

beak” tapering at the distal esophagus. Manometry is the gold standard for diagnosis of

achalasia and will show a loss of propulsive contractions in the esophageal body. Resting

pressures at the lower esophageal sphincter can be normal to elevated with incomplete or

completely absent relaxation upon swallowing. Esophagoscopy with biopsy is sometimes

needed to rule out distal esophageal stricture due to esophagitis or carcinoma, which can

mimic achalasia.

◆ Once the diagnosis of achalasia is made, treatment usually begins with nonsurgical thera-

pies. Botulinum toxin injected via an endoscope into the area of the lower esophageal

sphincter can relieve symptoms in 50% to 65% of patients for as long as 18 months. Most

have recurrence of symptoms beyond this time. Pneumatic or forceful bougie dilation of

the lower esophageal sphincter has a long-term success rate approaching 70%. The gold

standard for treatment of achalasia is surgical myotomy, with long-term success rates of

90% to 95%. Patients are usually treated with one or two attempts of nonsurgical therapies

before being referred to a surgeon for myotomy. Those who are poor surgical candidates can

be treated nonsurgically indeﬁ nitely.

◆ Informed consent is obtained from the patient who is given nothing by mouth 8 hours

before the procedure.

◆ General endotracheal anesthesia is administered for this procedure.

◆ The patient is placed in the lateral decubitus position with the right side down and secured

to the operating table. The bed can be bent at the seventh to eighth intercostal space to

facilitate exposure.

◆ The skin is prepped with povidone-iodine (Betadine), from the top of the shoulder

superiorly to the iliac crest inferiorly, then between the midline anteriorly and spinous

processes posteriorly.

CHAPTER 19 • Open Heller Myotomy 231

STEP 3: OPERATIVE STEPS

1. INCISION

◆ A muscle-sparing minithoracotomy incision measuring 8 to 10 cm is placed in the seventh

intercostal space (Figure 19-1, B). The serratus anterior muscle is separated to expose the

intercostal muscles, which are removed from the superior aspect of the eighth rib to enter

the chest. A rib retractor is placed.

2. DISSECTION

◆ A size 40F to 44F bougie or Maloney dilator is placed by the anesthesiologist to facilitate

dissection. The inferior pulmonary ligament is divided and the lung is retracted cephalad. The

mediastinal pleura overlying the esophagus is incised from the gastroesophageal junction to

the inferior pulmonary vein to expose the esophagus. This segment of esophagus is mobilized

anteriorly if only a myotomy is planned or is completely mobilized and encircled with a

Penrose drain if an antireﬂ ux procedure is added to the myotomy (Figure 19-2).

◆ Care should be taken during this dissection not to injure either vagus nerve located at the

lateral margins of the distal esophagus. Usually the vagus nerves are adherent and should

not be mobilized (see Figure 19-2, B-C).

232 Section III • The Esophagus

Anterior/posterior

vagus nerve

Esophagus mobilized

FIGURE 19 –2

vagus nerve

Anterior vagus

nerve

Bulge in

esophagus

CHAPTER 19 • Open Heller Myotomy 233

◆ The esophageal musculature is incised from the inferior pulmonary vein to the esopha-

geal hiatus and extended onto the cardia of the stomach for approximately 1 to 2 cm

(Figure 19-3).

Longitudinal muscle

Incision through circular muscle

Incision

Anterior vagus

nerve

FIGURE 19 –3

234 Section III • The Esophagus

◆ The esophageal muscle is gently divided longitudinally until the mucosa is seen to bulge

from underneath (Figure 19-4).

◆ A right-angle clamp or peanut dissector is used to raise the muscular wall from the mucosa

over approximately 50% of the esophageal circumference. Care must be taken not to enter

the esophageal lumen through the mucosa.

Submucosa

Circular

muscle

Longitudinal

muscle

FIGURE 19 –4

CHAPTER 19 • Open Heller Myotomy 235

◆ For the surgeon to inspect mucosal integrity, the bougie can be removed from the esopha-

gus upon completion of the myotomy and replaced by a nasogastric (NG) tube. The chest

cavity is ﬁ lled with saline irrigation while the anesthesiologist gently injects air through the

NG tube and the surgeon looks for air bubbles. If no air bubbles are seen, the Penrose drain

is removed and the esophagus returns to its normal position (Figure 19-5). If the mucosa

has been violated, the defect should be closed primarily with absorbable suture reapproxi-

mating the muscle ﬁ bers. An opposite site is then used for the myotomy.

◆ Following completion of the myotomy, a chest tube is placed in the pleural space and

exited through a separate incision in the lateral chest wall.

FIGURE 19 –5

236 Section III • The Esophagus

FIGURE 19 –6

◆ Antireﬂ ux procedure, if added, is either a Belsey Mark IV (270 degree), Nissen (360 degree),

or Dor (180 degree). Most surgeons add an antireﬂ ux procedure but no individual technique

has proven superior (Figure 19-6).

CHAPTER 19 • Open Heller Myotomy 237

3. CLOSING

◆ The rib retractor is removed, and interrupted 0 Vicryl sutures are placed around the sev-

enth and eighth ribs for closure of the chest cavity. Muscle layers are reapproximated with

running 2-0 absorbable suture. The skin is closed with staples or a running 4-0 absorbable

stitch. The chest tube is secured with a 2-0 silk drain stitch (Figure 19-7).

STEP 4: POSTOPERATIVE CARE

◆ After recovery from anesthesia, the patient can be taken to a ﬂ oor bed.

◆ The chest tube should initially be placed to 15 to 20 cm H

0 wall suction and the patient

kept NPO.

◆ On the second postoperative day, a contrast esophagram is obtained to ensure there is no

leak from the myotomy site. With no leak present, a diet is initiated. If no esophageal leak

is found, the lung is fully expanded. If there is no air leak present in the chest tube, the

tube is removed. Patients are usually ambulatory by the second postoperative day and dis-

charged to home by the third postoperative day.

FIGURE 19 –7