HELLER surgery opens the myocardium-esophagus layer

Cardiac spasm is a disease that occurs when the lower esophageal sphincter is not able to open on its own in response to the swallowing reflex. Therefore, food and saliva excreted while eating will be difficult or impossible to enter the stomach.
Common symptoms in patients with gastric spasm include:
Difficulty swallowing: Initially having difficulty swallowing with solid food, then having difficulty swallowing even with liquid food, the patient has a feeling that food is stuck or sticky back of the sternum; Vomiting: Appears immediately after eating. For people with long-standing achalasia and dilated esophagus, vomiting symptoms often appear late after eating; Reflux: It is possible to have gastroesophageal reflux right after eating or many hours after eating. In case of severe disease, the esophagus is dilated much, the patient may have reflux of food at night, causing coughing and choking; Chest pain: Pain behind the sternum and often pain when swallowing; Weight loss: Due to poor diet.

Treatment options for cardiac spasms include:
Medication: Usually only temporarily effective in the early stages, later not effective; Air balloon dilation: Can be dilated 1-3 times to be effective. However, this measure can cause bleeding complications or perforation of the esophagus; Injection of botulinum toxin into the lower esophageal sphincter: Works well, but usually only lasts about 6 months; Esophageal sphincter surgery (Heller surgery): Indicated when the above treatments fail. This is a surgical method to open the lower esophageal sphincter to release the blockage in the esophageal lumen, relieve symptoms of achalasia.

Heller surgery is a method of cutting open the myocardium - esophagus, while leaving only the mucosa and submucosa of the cardia - esophagus.
2.1 Indications/contraindications Indications
Treatment for patients with cardiac spasms confirmed by laboratory tests, X-rays, esophagoscopy - gastroduodenal surgery; Rare indications: In people with increased lower esophageal sphincter tone. Contraindications
Patient is too weak to tolerate surgery; The elderly, have many co-morbidities, weak health; Patients with esophageal cancer ; Contraindications to laparoscopic surgery: Localized or free ascites, surgical history of peritonitis, intestinal obstruction, abdominal wall hernia, umbilical hernia, local infection in the abdominal wall, coagulopathy; Contraindications to peritoneal inflation: Have valvular heart disease, coronary artery disease, chronic cardiopulmonary disease.

2.2 Preparation for surgery Personnel: Gastroenterologist, anesthesiologist, assistant; Technical means: The operating table can be rotated in all directions; laparoscopic surgery equipment system; unipolar and bipolar electrocoagulation systems; laparoscopic surgery kits; penrose (soft rubber tube); thread; open surgery kit. Patient: The surgery is explained in detail; basic pre-operative diagnostic tests (laparoscopic, X-ray, abdominal ultrasound); pre-operative improvement treatment; Insert a catheter to wash and drain stagnant fluid in the esophagus (if necessary), use prophylactic antibiotics; Medical records: Complete according to regulations. 2.3 Performing surgery Check the medical records and the patient, make sure the right person, the right disease; Anesthesia: Perform endotracheal anesthesia; Patient position: supine, head 15 - 30o high, legs apart, arms closed, knees straight or bent 20 - 30o; The surgical team stands in a convenient position for manipulation; Placing a trocar Resection of the small omentum, clearly exposing the right pillar of the diaphragm and the posterior X nerve; Open the peritoneum and connective tissue between the diaphragm and the esophagus, revealing the left pillar of the diaphragm; Using surgical forceps to dissect to create a window between the gastric aneurysm, diaphragm and 2 diaphragmatic pillars, then insert Penrose through the back of the esophagus, raise the esophagus anteriorly, and then dissect the esophagus to release the esophagus above the mediastinum; Cut the short gastric vascular branches from the middle of the body to the left border of the esophagus; Dissection clearly revealed the oesophageal-gastric junction, using ultrasound ablation to open the esophageal muscle to the submucosa at the 11 o'clock position of the esophagus, about 2 hours above the esophageal-stomach junction. - 3cm; From the initial position, separate the muscle layer from the submucosa with surgical forceps. Next, using an ultrasound knife to open the esophageal wall muscle up to 5-6cm from the gastroesophageal junction and open the stomach wall muscle down about 1cm from the gastroesophageal junction, stop bleeding carefully; Inflate the stomach to inflate the mucosa, check if there is a perforation of the esophagus - stomach lining, if there is a perforation, it is necessary to close the hole with suitable sutures; Withdrawal of penrose; Check carefully hemostasis and suture the trocar holes, complete the surgical procedure.

2.4 Follow-up after surgery Contrast esophageal X-ray after 24 hours after surgery; After 24 hours of surgery, the gastric tube should be removed; After gastric bypass, the patient should eat porridge. If the patient does not have abdominal pain or choking, he or she can be discharged from the hospital. 2.5 Complications and treatment 2.5.1 Perforation of the esophagus-stomach mucosa is the most common complication, which can occur at the time of surgical separation of the gastro-oesophageal muscle layer from the submucosa. When there is a perforation of the esophageal-stomach mucosa, the mucosa should be sutured with slow-dissolving sutures and pay attention to avoid narrowing the esophagus;
2.5.2 Pneumothorax The cause of this complication is the rupture of the pleura when dissecting the esophagus. After Heller surgery, if a pneumothorax is suspected, the physician should have the patient undergo a chest x-ray to detect it. In particular, because pneumothorax is often small and self-limited, pleural drainage is rarely required;
2.5.3 Perforation of esophageal mucosa causing peritonitis Re-operation should be performed to wash the abdomen, drain and suture the perforation. At the same time, it is recommended to open the gastrostomy to relieve pressure and open the jejunum for feeding.
Cardiac spasms need to be detected and treated early to avoid unwanted complications. Therefore, when there are warning signs of the disease, the patient should soon go for examination, make an accurate diagnosis and have appropriate treatment orientation such as medication, balloon ballooning or Heller surgical intervention.
If the patient shows unusual symptoms, it is best to immediately contact the treating doctor. All questions need to be answered by a specialist as well as if you have a need for examination and treatment at the General Hospital. Internationally, you can contact Vinmec Health System nationwide or register online HERE.