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Topic: Myotomy

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	eMedicine - Cricopharyngeal Myotomy : Article by Neil Bhattacharyya
		Myotomy may be considered if conservative measures fail, and there is radiologic evidence on the video fluoroscopic swallowing study (VFSS) of cricopharyngeal dysfunction that leads to a hesitation of bolus passage.
		Cricopharyngeal myotomy is contraindicated when the patient has a known tumor that involves the cervical esophagus or an otherwise correctable mucosal disease that involves the cervical esophagus or hypopharynx.
		Cricopharyngeal myotomy is also relatively contraindicated in patients who have undergone radiation therapy for head and neck cancer because the cricopharyngeus may be fibrotic and less apt to release when sectioned.
	www.emedicine.com /ent/topic602.htm (3657 words)

	Laparoscopic Myotomy
		The surgical therapeutic maneuver to relieve symptoms secondary to achalasia is an anterior esophageal myotomy (Heller myotomy).
		Once a patient is diagnosed with achalasia, we initially refer him to our invasive gastroenterologist who will inject the LES with Botulinum Toxin.
		These patients usually do well for an average of one year to 18 months at which time they can be routed toward a laparoscopic esophageal myotomy.
	www.laparoscopy.net /acha/acha3.htm (240 words)

	Laparoscopic Myotomy and Fundoplication for Achalasia
		Typically a myotomy with Dor hemifundoplication is performed for patients without a hiatal hernia, while reduction of the hernia, crural closure and Toupet hemifundoplication is preferred for patients with a hiatal hernia.
		Next, the myotomy is extended distally for a minimum of 2 cm onto the stomach along the greater curve side to divide the sling fibers at the angle of His (Video 5).
		Mucosal injuries during myotomy are more likely to occur in patients with prior therapy for achalasia, particularly Botox injection, and should be repaired with fine absorbable monofilament suture such as 4-0 PDS [2].
	www.ctsnet.org /sections/clinicalresources/thoracic/expert_tech-5.html (1285 words)

	Surgical intervention and treatment of oral, pharyngeal motor disorders : GI Motility online (Site not responding. Last check: )
		Myotomy for Zenker's diverticulum, for example, is consistently reported to have success rates in excess of 80%, whereas a review of 26 reports of myotomy including 419 patients for causes other than Zenker's diverticulum revealed a satisfactory outcome in only 61% of the cases.
		Although cricopharyngeal myotomy is intended to facilitate alimentation along the natural pharyngeal path, surgical enteral access bypasses the natural route with the goal of preventing aspiration and malnutrition.
		Physiologic response to cricopharyngeal myotomy and diverticulum suspension.
	www.nature.com /gimo/contents/pt1/full/gimo51.html (9922 words)

	THE MERCK MANUAL OF GERIATRICS, Ch. 105, Esophageal Disorders
		Mechanical disruption of the lower esophageal sphincter using pneumatic dilatation or surgical myotomy has been the principle method of treatment when drug treatment and botulinum toxin have not been effective.
		Surgical myotomy is indicated when repeated pneumatic dilatations over a relatively short duration are necessary to maintain lower esophageal sphincter patency.
		A modified Heller's procedure (anterior myotomy of the circular muscle fibers of the lower esophageal sphincter, preserving the sphincter competency) is successful in 80 to 90% of patients.
	www.merck.com /mrkshared/mmg/sec13/ch105/ch105c.jsp (620 words)

	Baylor Health Care System: Achalasia: Willis or Heller?
		A long myotomy ensures division of all the lower esophageal high-pressure zone circular muscle fibers and may prevent chest pain from nonpropagated simultaneous contractions or diffuse esophageal spasm (8, 11, 20).
		Following myotomy, we use esophagoscopy to confirm adequacy of the myotomy and air insufflation with the esophagus submerged in saline to ensure that there is no unrecognized perforation.
		Heller myotomy is superior to dilation for the treatment of early achalasia.
	www.baylorhealth.edu /proceedings/12_4/12_4_vanderpool.html (2802 words)

	Gastroenterology Grand Rounds
		The 10 yr remission rate was 77% in pts undergoing myotomy, 72% in pts successfully treated with a single PD and 45% in pts undergoing several dilations.
		Myotomy was therefore shown to be an effective treatment modality in patients with achalasia who have failed to respond to PD.
		The reason for failure was incomplete myotomy in five, incorrect diagnosis in two, and new onset of reflux symptoms in one.
	www.bcm.edu /gastro/DDC/grandrounds/BCM/3-24-05/09-DISC.HTM (1462 words)

	Laparoscopy.com - ESOPHAGEAL MYOTOMY.
		Professor A.Cuschieri, MD is presenting a case of esophageal myotomy via thoracoscopy.
		The ideal treatment for achalasia should include the precision and efficacy of myotomy and the absence of laparotomy: exactly the advantages of videolaparoscopic cardiomyotomy.
		Once myotomy has been completed, one notes the characteristic protruding aspect of the oesophageal mucosa along the tract where the muscle wall has been freed.
	www.laparoscopy.com /pictures/myotomy.html (453 words)

	Heller myotomy
		Heller myotomy is a form of surgery in which the muscles of the cardia (lower esophageal sphincter) are cut, allowing food/liquid to pass to the stomach.
		Modern Heller myotomy is performed using minimally invasive laparoscopic techniques, which minimize risks and speed recovery significantly.
		Though it does not correct the underlying cause(s) and does not result in the complete absence of achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink.
	www.mrsci.com /Surgery/Heller_myotomy.php (221 words)

	s001117a - Esophageal Achalasia
		Laparoscopic myotomy with combined antireflux surgery is an increasingly attractive option in younger patients with achalasia, but long term follow-up studies are required to establish its efficacy and the potential for reflux-related sequelae.
		Surgical myotomy, once with high morbidity and long hospital stay, can now be performed laparoscopically with similar efficacy to the open surgical approach (94% vs. 84%, respectively), reduced morbidity, and hospitalization time.
		Abstract: Achalasia is an esophageal motility disorder of unknown cause, characterized clinically by dysphagia and regurgitation and diagnosed by manometry and/or barium esophagogram.
	www.emory.edu /WHSCL/grady/amreport/litsrch00/s001117a.html (2037 words)

	Revista do Hospital das Clínicas - Effects of circular myotomy on the healing of esophageal suture anastomosis: an ... (Site not responding. Last check: )
		In the myotomy group, a complete circumferential division of both muscle layers was performed in the proximal esophageal segment 1.5 cm from the resected end, according to the original description of Livaditis.
		After the completion of the anastomosis, it was noted in the myotomy group that the musculature of the esophagus retracted markedly, exposing at least 2 to 3 cm of the underlying submucosa.
		The circular myotomy neutralizes the tonus of the esophageal musculature, but cannot exert any effect on the submucosa, which is predominantly made up of elastic connective tissue with a loose attachment to the overlying musculature.
	www.scielo.br /scielo.php?script=sci_arttext&pid=S0041-87811999000100003&lng=es&nrm=iso (4565 words)

	Esophagus - Endoscopic Submucosal Esophageal Myotomy: 'Third Spacing' for the Endoscopist
		The gold standard for the treatment of achalasia is a surgical myotomy of the lower esophageal sphincter.
		The myotomy is extended from a distal to a proximal manner.
		This is a view of the myotomy and you can see the oblique fibers exposed and we are now pulling out of this space and back into the lumen.
	daveproject.org /ViewFilms.cfm?film_id=601 (660 words)

	American Pediatric Surgical Association :: Resources : Achalasia
		For the laparoscopic esophageal myotomy, the placement of the incisions is similar to that used for fundoplication (Figure 1).
		Identical instruments are employed for a laparoscopic esophageal myotomy as for a laparoscopic fundoplication.
		With an operative plan of myotomy and anterior fundoplication, the initial step is to divide the blood vessels connecting the stomach and spleen in order to free the upper stomach.
	www.eapsa.org /parents/resources/achalasia.cfm (1331 words)

	World J Gastroenterol
		Myotomy in combination with antireflux procedure can prevent gastroesophageal reflux to a certain extent, but further randomized studies should be carried out to demonstrate its efficacy.
		Myotomy was performed from 5 cm above the esophagogastric junction to 1.5 cm distal to the esophagogastric junction for all of the 176 patients.
		Heller’s myotomy in combination with antireflux procedure could stop gastroesophageal reflux to a certain extent, but a large number of patients should be studied randomly to further demonstrate its efficacy.
	www.wjgnet.com /1007-9327/10/287.asp (2866 words)

	Surgical treatment for achalasia : GI Motility online
		To clear a path for the myotomy across the GEJ, we resect the cardioesophageal fat pad to the left of the anterior vagus nerve while simultaneously mobilizing the vagus from the esophagus.
		The myotomy is begun approximately 3 cm below the GEJ and an L-shaped hook electrocautery device is used to divide the muscle fibers.
		The most difficult dissection involves the 3-cm myotomy on the stomach where the plane of dissection becomes blurred with intervening sling muscular fibers and the underlying gastric mucosa is thinner, increasing the risk of perforation.
	www.nature.com /gimo/contents/pt1/full/gimo53.html (5131 words)

	Minimally Invasive Surgery - Laparoscopic Heller Myotomy (cardiomyotomy)
		The myotomy is performed by separating the outer longitudinal muscle layer and incising the inner circular mucle layer.
		Distally, the myotomy is carried across the gastroesophageal junction and on to the stomach for about 1-2 cm.
		Once the myotomy is completed, the muscle edges are separated from the underlying mucosa for approximately 40% of the esophageal circumference.
	www.hmc.psu.edu /mis/services/heller.htm (954 words)

	Laparoscopic Heller Myotomy (Site not responding. Last check: )
		Laparoscopic Heller myotomy is used to treat esophageal achalasia, a disorder of the esophagus.
		Achalasia is when the esophagus is less able to move food toward the stomach, and the valve from the esophagus to the stomach does not relax as much as it needs to during swallowing.
		Not all patients are candidates for the Laparoscopic Heller myotomy and may require an open surgery.
	www.utmedicalcenter.org /utm_minimally_invasive_procedures/mip_procedures/laparoscopic_heller_myotomy (199 words)

	BioMed Central \| Full text \| Treatment of achalasia: the short-term response to botulinum toxin injection seems to be ...
		Pneumatic balloon dilatation of the lower oesophageal sphincter is regarded as the treatment of choice in these patients; however, balloon dilatation is limited by success rates of 80–85% and the possibility of oesophageal perforation, which may occur in 1.3–1.5% of cases [9-12].
		It has previously been shown that intrasphincteric injection of botulinum toxin can be used in the treatment of achalasia, leading to an improvement of clinical symptoms and objective parameters, [15,17] and this finding has been confirmed by several other groups [17,21-27].
		Whereas retrospective studies have shown that myotomy and pneumatic dilatation are equally effective, randomised prospective studies have found that pneumatic dilatation is superior to botulinum toxin injection, since patients treated with botulinum toxin need regular repeat treatments during the further course.
	www.biomedcentral.com /1471-230X/2/19 (4271 words)

	SSAT - 2005 Abstracts: Age, More Than Duration of Symptoms, Impacts Symptoms of Achalasia and Outcomes After Myotomy (Site not responding. Last check: )
		Presumably, prior to myotomy, duration and severity of symptoms will be inversely related and age will reflect duration of symptoms.
		This study was undertaken to determine the relationships among age, duration of symptoms, severity of symptoms, and outcome after laparoscopic Heller myotomy.
		Conversely, age at myotomy correlated with severity of premyotomy regurgitation (p < 0.05), and the lack of postmyotomy choking (p < 0.01) and heartburn (p < 0.05), and superior outcomes (p < 0.05).
	www.ssat.com /cgi-bin/abstracts/05ddw/SSAT_DDW05_155.cgi (407 words)

	Are the results of myotomy altered by previous dilatations?
		Pinotti [2] reported on 92 patients who experienced previous pneumatic dilatation failures and were treated thereafter by myotomy and fundoplication with "no statistically significant difference found on comparing the cases with and without previous dilatation (excellent results in 83.9%)".
		Martins [5] reports on a group of chagasic megaesophagus which presented 30 recurrences of pneumatic dilatation, which were treated by surgery with good results in 23 cases (76.6%).
		Parkman [6] reported as well, that 15 patients with failure to pneumatic dilatation were submitted to surgical myotomy with good clinical and X-ray results in 100% of the cases.
	www.hon.ch /OESO/free/Vol_5_Eso_Junction/Articles/art411.html (436 words)

	Keck : Department of Surgery : Clinical Activities : Esophageal Motor Disorders
		In these patients an esophageal myotomy of the lower sphincter can be done laparoscopically or thorascopically, providing marked relief for patients with this abnormality.
		Above: For patients who suffer from achalasia, the inability to pass food from the esophagus into the stomach, an esophageal myotomy is performed.
		The instruments are exposing the muscle of the sphincter in preparation for the myotomy.
	www.usc.edu /schools/medicine/departments/surgery/divisions/thoracic/clinical/esoph.html (182 words)

	What is a Myotomy?
		A common example of myotomy is a procedure known as Heller myotomy.
		Heller myotomy is used to treat achalasia, a condition in which the cardia is unable to relax properly and the sufferer is unable to swallow liquids or food.
		Heller myotomy is performed by cutting the muscles of the cardia, the lower esophageal sphincter.
	www.wisegeek.com /what-is-a-myotomy.htm (357 words)

	Laparoscopic Myotomy for Achalasia
		Historically, definitive surgical treatment for patients with achalasia included a formal rib spreading incision to perform an esophageal myotomy or splitting of the abnormally thickened esophageal muscle at the lower sphincter.
		We are currently performin a laparoscopic myotomy for most of our achalasia patients.
		After completion of this myotomy a gastric fundoplication or loose stomach wrap is created around the esophagus to minimize reflux.
	www.nyp.org /masc/myotomy.htm (345 words)

	Does an initial myotomy contraindicate subsequent dilation ?
		This procedure has been added because of the significant number of acid-reflux sequelae after myotomy when a careful postoperative follow-up is extended up to 10 years.
		The obvious intent of an antireflux procedure superimposed on a myotomy, i.e., a second operation intended to compensate for deficiencies induced by the first operation, is to reduce damaging reflux without altering esophageal emptying a worthy goal but a difficult one to achieve.
		Consequently, any patient with significant prolonged dysphagia relief after myotomy, with or without a history of postoperative acid-reflux symptoms, who develops recurrent dysphagia, must be suspected of having reflux esophagitis and/or stricture.
	www.hon.ch /OESO/free/Vol_4_Prim_Motility/Articles/ART176.HTML (270 words)

	[No title]
		The myotomy is initiated 5 to 6 cm proximal to the anticipated location of the gastroesophageal junction.
		The lateral side walls of the myotomy are extended to complete an 180 degree mucosal exposure.
		The proximal extent of the myotomy is established based on the extent of the disease by preoperative contrast esophagogram and manometry.
	www.bgsm.edu /surg-sci/atlas/heller.htm (816 words)

	Ciné-Med - Laparoscopic Heller Myotomy for Achalasia in a Pediatric Patient
		The anatomical approach (thoracoscopic or laparoscopic) lacks any evidence based series and there is likely to never be any randomized trial answering the question of an optimal age or approach for management of the child with achalasia.
		He was ultimately referred for surgical consultation, and Heller myotomy with anterior fundopolication was recommended.
		The procedure was undertaken using 5 abdominal trocars, ranging in size from 5mm to 12mm positioned at the umbilicus, bilateral subcostal midclavicular lines, right anterior auxillary line at the subcostal margin, and subxiphoid.
	www.cine-med.com /index.php?nav=surgery&subnav=acs&id=ACS-2381 (312 words)

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