esophagomyotomy

Esophagomyotomy, or esophageal myotomy, is a surgical procedure that cuts the circular muscle fibers of the distal esophagus and often the cardia to relieve functional obstruction from motility disorders. It is most commonly performed to treat achalasia, but can be used for other conditions such as diffuse esophageal spasm or esophagogastric junction outflow obstruction. The procedure aims to reduce the pressure at the lower esophageal sphincter to improve bolus passage into the stomach.

The most widely performed form is the Heller myotomy, typically done laparoscopically or robotically. It may be accompanied by a partial fundoplication (such as Dor or Toupet) to reduce postoperative gastroesophageal reflux. An alternative approach is peroral endoscopic myotomy (POEM), an endoscopic technique that creates a submucosal tunnel and performs a myotomy from within the lumen, avoiding external incisions.

Indications include symptomatic achalasia of various subtypes, select non-achalasia motility disorders, and cases where medical or endoscopic therapies have failed. Contraindications include advanced megaesophagus with poor esophageal function, significant comorbidity that increases surgical risk, or suspicion of malignant obstruction requiring oncologic treatment.

Technique details vary by approach. A Heller myotomy extends about several centimeters above the gastroesophageal junction and into the proximal stomach; the inner circular muscle is divided while preserving mucosa, with a partial fundoplication added to mitigate reflux. POEM uses a submucosal entry to access and dissect the muscle prior to completing the myotomy.

Outcomes are generally favorable, with substantial relief of dysphagia in many patients, though postoperative reflux can occur. Complications are relatively uncommon but can include mucosal perforation, infection, or bleeding. Recovery is typically short, with a gradual return to normal diet and activity. The Heller procedure dates from the early 20th century, while POEM is a more recent development.