Achalasia Cardia Surgical Procedures: History, Background and a Worked Example

Defining Achalasia Cardia

Achalasia cardia is a motility disorder of the esophagus in which the lower esophageal sphincter fails to relax properly and the esophageal body loses normal peristaltic waves. This leads to difficulty swallowing, regurgitation of undigested food, chest pain and weight loss. The condition is idiopathic in most cases, though rare familial or secondary forms exist.

Diagnosis relies on a combination of barium swallow, esophageal manometry and endoscopy. Manometry shows incomplete sphincter relaxation and absent peristalsis, while the barium study often reveals a dilated esophageal lumen with a "bird‑beak" taper at the sphincter. Endoscopy excludes neoplastic causes.

Understanding the pathophysiology guides therapeutic choices. Because the primary problem is a non‑relaxing sphincter, treatments aim to reduce its pressure mechanically or pharmacologically. Surgical options remain the most durable approach for long‑term symptom relief.

Early Surgical Concepts and the First Heller Myotomy

The first recorded surgical attempt to relieve achalasia dates to 1913 when Ernst Heller performed a longitudinal myotomy of the lower esophageal sphincter via an open transabdominal approach. Heller’s procedure divided the circular muscle fibers of the sphincter while preserving the mucosal layer, aiming to create a permanent low‑pressure zone.

Initial results were promising but the technique carried significant morbidity due to large incisions, prolonged hospitalization and a risk of postoperative reflux. Surgeons refined the operation over the following decades, adding anti‑reflux procedures such as a Dor fundoplication to mitigate acid exposure.

These early open Heller myotomies established the principle that mechanical disruption of the sphincter could alleviate dysphagia, laying the groundwork for all subsequent minimally invasive adaptations.

From Open to Laparoscopic Heller Myotomy

The advent of video‑assisted laparoscopy in the late 1980s allowed surgeons to replicate Heller’s myotomy through several small abdominal ports. The first laparoscopic Heller myotomy was reported in 1991, demonstrating comparable dysphagia relief with markedly reduced postoperative pain and shorter hospital stays.

Laparoscopic access also facilitated the routine addition of a partial fundoplication (usually Dor or Toupet) to prevent gastroesophageal reflux, a combination that became the standard of care for surgical achalasia treatment throughout the 1990s and early 2000s.

Long‑term follow‑up studies showed that laparoscopic Heller myotomy with fundoplication provided sustained improvement in Eckardt scores for the majority of patients, reinforcing its role as a durable therapeutic option.

Emergence of Peroral Endoscopic Myotomy (POEM)

In 2008, Japanese endoscopist Professor Inoue introduced peroral endoscopic myotomy, a purely endoscopic technique that creates a submucosal tunnel in the esophageal wall and performs a myotomy of the lower esophageal sphincter from inside the lumen. POEM avoids external incisions entirely.

The procedure is performed under general anesthesia with the patient in the supine position. After mucosal entry near the upper esophageal sphincter, a tunnel is dissected posteriorly to the cardia, where the circular muscle fibers are cut over a length of approximately 8–10 cm. The mucosal entry site is then closed with endoscopic clips.

POEM quickly gained popularity because it achieves sphincter disruption comparable to Heller myotomy while eliminating the need for abdominal incisions. Early series reported excellent dysphagia relief and low rates of severe postoperative reflux, although long‑term data on reflux outcomes are still being collected.

Scenario Walkthrough: Mr. Patel’s Journey Through Diagnosis and Surgery

Mr. Patel, a 52‑year‑old schoolteacher, presented with a six‑month history of progressive dysphagia to solids and liquids, accompanied by regurgitation of undigested food after meals and occasional chest discomfort. He lost 5 kg despite a normal appetite. His primary care physician ordered a barium swallow, which showed a dilated esophagus with a characteristic bird‑beak narrowing at the lower esophageal sphincter.

Esophageal manometry confirmed absent peristalsis in the esophageal body and incomplete relaxation of the lower esophageal sphincter with an integrated relaxation pressure of 22 mm Hg (normal < 10 mm Hg). Endoscopy revealed a patent lumen without mucosal lesions, ruling out malignancy. The multidisciplinary team diagnosed idiopathic achalasia cardia.

Given Mr. Patel’s good overall health and his preference for a durable solution with minimal external scarring, the team recommended a laparoscopic Heller myotomy with a Dor fundoplication. Under general anesthesia, five ports were placed, the esophageal hiatus was identified, and a 6‑cm longitudinal myotomy was performed on the distal esophagus and proximal stomach. A Dor anterior fundoplication was then constructed to cover the myotomy site. Post‑operatively, Mr. Patel began a liquid diet on day 1, advanced to soft foods by day 3, and was discharged on postoperative day 2. At his six‑week follow‑up, his Eckardt score had dropped from 8 to 1, and he reported normal swallowing without regurgitation.

How Historical Developments Influence Current Surgical Options

The evolution from open Heller to laparoscopic Heller and finally to POEM illustrates a clear trend toward less invasive access while preserving the core therapeutic goal: reducing lower esophageal sphincter pressure. Each step built on the lessons of its predecessor—learning to control reflux, optimizing myotomy length, and minimizing tissue trauma.

Today, clinicians weigh three primary surgical pathways when counseling patients: laparoscopic Heller myotomy with fundoplication, robotic-assisted Heller myotomy (which offers enhanced dexterity but similar outcomes), and peroral endoscopic myotomy. The choice hinges on factors such as patient anatomy, prior abdominal surgeries, surgeon expertise, and patient preferences regarding external incisions versus endoscopic approach.

Historical data also inform postoperative management. Early Heller series highlighted the importance of routine anti‑reflux measures, a practice that persists in laparoscopic Heller but is debated in POEM, where selective proton‑pump inhibitor use is guided by individual reflux symptoms.

Future Directions and Ongoing Research

Current research seeks to refine both laparoscopic and endoscopic techniques. Investigational efforts include tailored myotomy lengths based on manometric pressure gradients, bio‑absorbable anchors to reinforce the myotomy site, and integrated anti‑reflux modalities specifically designed for POEM.

Artificial‑intelligence‑assisted maneuvering during endoscopic submucosal tunneling is under trial to reduce variability in tunnel creation and myotomy completeness. Simultaneously, multicenter registries are collecting long‑term data on symptom recurrence, reflux esophagitis, and functional outcomes to better define the durability of each approach.

As technology advances, the fundamental principle established over a century ago—mechanical reduction of sphincter obstruction—remains unchanged, while the methods of achieving it continue to become safer, more precise, and increasingly patient‑centered.