Achalasia Surgery (Heller Myotomy)


Achalasia is a condition that makes swallowing difficult. This occurs when the muscles around the lower part of the esophagus, called the lower esophageal sphincter, or LES, do not relax to allow food to pass into the stomach. The muscles in the esophagus don't function properly to move food into the stomach either. Common symptoms include the feeling of food and/or liquid being stuck in the lower chest (dysphagia), burning chest pain after eating (indigestion), and regurgitation of bitter tasting fluid or partially digested food. Atypical symptoms include coughing, asthma, or other breathing difficulties.

Treatment of achalasia is aimed at decreasing the pressure in the LES to allow food to pass into the stomach. The LES can be stretched with a balloon or the muscles relaxed by injecting Botox. These therapies are effective in the short term, but rarely result in long term cure. Repeated procedures are necessary in most cases, with increasing risks of the procedure each time. Surgery, however, has the best results, with over 90% of patients having good long term results. Surgery involves cutting the muscle layers around the lower part of the esophagus, called a Heller myotomy, to allow passage of food into the stomach. This can usually done laparoscopically, though may require open surgery. This surgery normally includes a reflux operation as well, which wraps a portion of the stomach around the lower esophagus to prevent reflux of stomach contents back up into the esophagus.

Most surgery for achalasia is done as an elective procedure and requires you to stay in the hospital 1-2 days. You will usually have an x-ray swallowing study done the morning after surgery. If the study is okay, you will be started on a liquid diet before being sent home. You will have specific diet restrictions after achalasia surgery and will be given instructions on how to advance your diet at home.

Preoperative Information

Prior to Heller myotomy, you will be asked not to eat or drink anything after midnight prior to your surgery. You will be given specific instructions from your surgeon or anesthesiologist about which medications you should or should not take prior to your surgery. You should not take any blood thinning medications, such as aspirin, Ibuprofen, Coumadin, Plavix, or goody's powder at least 5 days prior to your operation. This should be discussed with your surgeon at your preop visit.

Your work up before having Heller myotomy will include an upper endoscopy to look directly at the esophagus and stomach and take any biopsies, if necessary. A swallowing study (x-ray study) is also needed to show if the esophagus is narrowed at its lower end and the condition of the esophagus above the area of narrowing. You will also have a study that evaluates the ability of the esophageal muscles to push food toward the stomach, and the ability of the LES to relax when you swallow. This is called manometry and involves placing a small catheter lined with pressure sensors down your esophagus. This is done by a Gastroenterologist, a physician specializing in gastrointestinal disease and endoscopy.

You will also have a detailed discussion with your surgeon about the risks and benefits of Heller myotomy, including the possibility that your symptoms will not get better or that you may need to take reflux medications to help control reflux you might experience postoperatively. If x-ray studies and manometry show a significant narrowing of the lower esophagus, there is a good chance you will benefit from Heller myotomy.

Postoperative Information

Heller myotomy can be performed laparoscopically. In this case, you will stay in the hospital overnight and likely be discharged 1-2 days after surgery.

In the event that you require an open Heller myotomy, you may have to stay in the hospital a little longer for pain control, though not in all cases.

You will have a swallowing study done the morning after surgery. This is to make sure there is no leak from the esophagus from the surgery. If the swallow study is normal, you will be given a liquid diet and you will start preparing to go home.

Activity
You can resume most usual activities gradually beginning shortly after surgery. You should begin walking the night of surgery or the following morning and continue to increase as you are able. Increased activity reduces the risk of blood clots, and improves breathing to prevent pneumonia

While in the hospital, you will be asked to walk several times a day, beginning no later than the morning after surgery in most cases. You will usually need assistance to get out of bed, especially the first time, since you will likely have IV tubing and sometimes drains or catheters that need to be disconnected in order for you to get around. A Physical Therapist often helps you get out of bed and regain your strength after major surgery. Walkers, canes or crutches will be made available as needed. In some cases a short stay in a rehabilitation center or short-term nursing home may be needed. This is uncommon and usually only needed for people who had to have emergency operations or had some other complications and a long hospital stay.

After discharge from the hospital, avoid lifting more than 10 pounds for 2-4 weeks and excessive bending or twisting for 1-2 weeks following surgery. This is to allow healing of the incisions, specifically the fascia (the strongest layer of the abdomen wall) and decrease the risk of a hernia developing. For laparoscopic surgery there may be less risk for developing a hernia and it may be safe to return to unrestricted activity sooner.

Avoid driving until you no longer need narcotic pain medication and you feel you can make rapid movements unimpaired by pain. Driving while taking narcotics can impair your ability to drive safely.

You should be able to return to work in 1-2 weeks. If your job involves heavy lifting and light duty is not an option, you may need up to 4 weeks off work to recover

Wound Care, Drain Care, Ostomy Care
If your Heller myotomy was done laparoscopically, small gauze and clear tape dressings or a small white dressing is typically placed over each incision. These dressings may be removed 48 hours (2 days) after the operation. If you are in the hospital more than one day, these may be removed before you leave the hospital. Below this dressing are small brown or white pieces of tape (called Steri-Strips); these will fall off on their own within 1-2 weeks or be removed at your follow-up visit with your surgeon. If your surgeon gives you specific instructions other than this, please follow those instructions.

If your Heller myotomy was done as an open procedure, you will probably have a long white dressing or gauze and tape dressing over your incision. This dressing may be removed 48 hours (2 days) after the operation and will probably be removed before you leave the hospital. Your incision will probably be closed with small metal staples. These will be removed at your postop visit, usually 10-14 days after your operation. If you are in the hospital more than a week, these may be removed before you go home.

You may shower after 48hrs (after the gauze and clear tape dressing is removed). It is okay to get soap and water on the incisions. Pat the area dry. You will be able to shower in the hospital after 48hrs as well. Your nursing staff can assist you if needed. It is not recommend that you submerge underwater (in a bathtub, pool, or hot-tub) for at least two weeks post-op.

If you notice drainage from your incisions, particularly if it is thick and foul-smelling or associated with a fever, contact your surgeon.

If you notice redness around your incisions, especially if it is getting worse or associated with drainage or a fever, contact your surgeon.

Medications - Pain Management
Pain after a large open operation can be significant. You will most likely be placed on IV narcotics using a pump (PCA  patient controlled analgesia), which allows you to press a button for additional medication when you need it. This will be weaned off within a few days of your operation and you will start oral pain medications. It is very important to us that your pain be well controlled. Your pain should be controlled well enough for you to begin getting out of bed the morning after surgery and for you to perform deep breathing exercises. If you have pain that is not well enough controlled to allow you to walk or breathe deeply, talk to your surgery team. You may need to have your pain medications changed or increased.

If your Heller myotomy is performed laparoscopically, pain is typically just around the site of incisions. However, you may have more general abdominal pain or even shoulder pain due to the air used to inflate your abdomen during the surgery. Pain from air inflation will go away in 24 to 48 hours. If an open operation is needed, there may be more pain during the first few days after surgery.

You will be discharged with pain medication, typically a mild to moderate strength narcotic. Take as needed and as prescribed. You may also take over-the-counter medications such as ibuprofen for pain. Most narcotic medications prescribed are combined with Tylenol (acetaminophen) and you should not take additional Tylenol if you are taking a narcotic medication that already contains Tylenol.

Nausea
It is very important to control any nausea you might experience after your surgery, particularly if the stomach is wrapped partially or completely around the esophagus as part of the surgery to reduce any anticipated postoperative reflux. You will have access to IV anti-nausea medication throughout your hospital stay. Oral anti-nausea medication or rectal suppositories that can control nausea will be prescribed as needed upon hospital discharge. Please let your surgeon know if you develop nausea after discharge so that he or she can address this further.

Other Medications
You will likely be prescribed a stool softener when you go home. Pain medications can cause constipation and a stool softener may help. You may also be given nausea medication if you experience nausea or vomiting from taking your pain medication.

Home Medications
Unless otherwise instructed, you should be able to resume your usual home medications the night of or the morning following your surgery.
Click here for more detailed information on commonly prescribed medications.

Diet & Bowel Care
Following achalasia surgery, you will be given specific diet instructions and be seen by a nutritionist.

  • You will probably be limited to liquids for the first week after surgery.
  • Eat small and frequent meals rather than the typical three large meals a day.
  • Limit fluid intake during meals (usually only about  cup or 4oz). Between meals you may drink more fluid.
  • Do not drink any carbonated beverages.
  • Do not drink through a straw.
  • Take small bites and chew food very well to avoid “sticking” of food at the site of your reflux operation.
  • Avoid foods that cause bloating or gas (such as broccoli, beans, cabbage).
  • Avoid caffeine and alcohol.

For more details about diet after Heller myotomy

Many patients will notice their stomach feels very full quickly and have bloating after having achalasia and reflux surgery. This happens because you are not able to belch normally after reflux surgery. Eating smaller meals, separating intake of solids and liquids, and avoid foods or drinks that you know make you gassy (such as carbonated beverages, alcohol, some vegetables) will help with these symptoms. You may also need to take nausea medication prescribed by your doctor. This usually gets better within a few weeks after surgery when the swelling of the stomach wrap goes down.

It is common to have some constipation after surgery, especially when taking narcotic pain medications. You will probably be prescribed a stool softener when you are discharged. If you are having trouble moving your bowels after surgery (if your stool is hard or you have to strain excessively) you may need a laxative. Over the counter medications can treat this well. Senna, Miralax, or dulcolax are some of the most common and are available at most drug stores or grocery stores. Take as directed.

If you experience problems having a bowel movement AND have abdominal bloating, nausea or vomiting, and not passing gas, call your doctor.

Follow Up
You will be given a date and time to see your surgeon following surgery, usually in 3 weeks if you had a laparoscopic operation and 10-14 days if you had an open operation. If you are discharged late in the day or over the weekend, you will be given a number to call the following business day for an appointment. If you are having trouble making an appointment, call your doctors' office directly for assistance.

Call Your Doctor If:

  • You have a fever of 101 F or higher. This could be a sign of infection.
  • You have redness around your incisions. This could be a sign of skin infection or deeper infection.
  • You have drainage from your incisions, particularly if it is thick and foul smelling. This could be a sign of a deeper infection.
  • You have nausea or vomiting or abdominal distention (bloating).
  • You have severe pain with swallowing or in your stomach after eating.
  • Food “sticks” in the lower part of your esophagus.
  • Your pain gets worse or is not relieved by your prescription pain medications.
  • Your are not making urine as you were before your operation
  • You develop worsening swelling in your legs or have sudden shortness of breath. This could be a sign of blood clots.
  • You have shortness of breath and/or chest pain

Contact Information

Daytime hours: Call 706-21-4686 or 7597
After hours and weekends: Call 706-21-8400