CPT® Code 32665

1. Indications

Esophagomyotomy (Heller type) is indicated for patients suffering from specific esophageal motility disorders. The primary conditions for which this procedure is performed include:

• Achalasia - A condition characterized by the inability of the lower esophageal sphincter to relax, leading to difficulty in swallowing and food obstruction.
• Esophageal spasm - A disorder that causes intermittent contractions of the esophagus, resulting in chest pain and swallowing difficulties.
• Other motility disorders - Conditions that affect the normal movement of the esophagus, causing symptoms such as dysphagia (difficulty swallowing) and regurgitation.

2. Procedure

The procedure for thoracoscopy with esophagomyotomy involves several critical steps to ensure successful surgical intervention. The following outlines the procedural steps:

• Step 1: Incision and Access - A small posterolateral incision is made between the ribs, typically at the fourth, fifth, or sixth intercostal space, near the posterior aspect of the axillary line. This incision allows for the introduction of the videothoracoscope, providing the surgeon with a visual perspective of the esophagus from above.
• Step 2: Additional Portal Incisions - Two additional portal incisions are created, one anterior and one posterior to the esophagus, to facilitate the introduction of surgical instruments necessary for the procedure.
• Step 3: Lung and Diaphragm Retraction - Further portal incisions are made, and retractors are inserted to retract the lung and diaphragm, thereby providing better access to the pleural space and the esophagus.
• Step 4: Creation of Pneumothorax - The pleural space is entered, and air is injected to create an artificial pneumothorax, which collapses the lung and enhances visibility and access to the surgical site.
• Step 5: Identification and Retraction of the Esophagus - The distal esophagus is identified and retracted using a flexible esophagoscope, allowing for precise manipulation during the incision process.
• Step 6: Incision of the Esophageal Muscular Layer - The muscular layer of the esophagus is incised longitudinally down to the submucosa using endoscopic scissors or hook cautery. This incision is extended approximately 0.5 cm into the stomach to ensure adequate relief of the obstruction.
• Step 7: Placement of Chest Tube - Following the completion of the esophagomyotomy, a chest tube is placed through one of the existing portal incisions to facilitate drainage and prevent complications.
• Step 8: Lung Re-expansion and Closure - The lung is re-expanded, and the portal incisions are closed. A nasogastric tube is then placed to assist with postoperative care and management.

3. Post-Procedure

After the thoracoscopy with esophagomyotomy, patients typically require monitoring for any complications related to the procedure. Expected recovery includes management of pain, monitoring for signs of infection, and ensuring proper function of the esophagus. The placement of a nasogastric tube aids in the initial postoperative feeding protocol, allowing for gradual reintroduction of oral intake as tolerated. Patients may also be advised on activity restrictions and follow-up appointments to assess healing and the effectiveness of the procedure.