Achalasia / Heller Myotomy

Introduction

If you have been told you have achalasia, you have probably already lived with months or years of difficulty swallowing, regurgitation of undigested food, chest discomfort, and unexplained weight loss before reaching a diagnosis. Achalasia is uncommon, and many people are investigated for other conditions first. By the time the diagnosis is clear, the next question is usually about treatment — and the most established surgical treatment is an operation called the Heller myotomy.

This article is written for someone who already has a diagnosis of achalasia, or is being investigated for it, and is now planning treatment. It explains what achalasia is, how it is diagnosed, the treatment options doctors commonly use, what a Heller myotomy involves, and what recovery and long-term life with treated achalasia typically look like. It also covers alternatives such as per-oral endoscopic myotomy (POEM), pneumatic dilation, and botulinum toxin injection, because the choice between these is an important conversation to have with your gastroenterologist and surgeon.

What Is Achalasia?

Achalasia is a disorder of the oesophagus, the muscular tube that carries food from your mouth to your stomach. In a healthy oesophagus, two things happen each time you swallow. First, the muscle of the oesophagus contracts in a coordinated wave (called peristalsis) to push food downward. Second, a ring of muscle at the bottom of the oesophagus, called the lower oesophageal sphincter (LES), relaxes to let food pass into the stomach.

In achalasia, both of these processes fail. The peristaltic wave is weak, disorganised, or absent, so food is not pushed down properly. At the same time, the lower oesophageal sphincter does not relax fully, so the path into the stomach stays partly blocked. Food and liquid collect above the tight sphincter, stretching the oesophagus over time. The word “achalasia” itself comes from Greek and means “failure to relax.”

The underlying problem is damage to the nerve cells in the wall of the oesophagus that normally coordinate muscle activity. Why this damage occurs is not fully understood. Most cases are thought to involve an immune-mediated process, possibly triggered by a viral infection in a genetically susceptible person. Achalasia is rare, affecting roughly one to three people per 100,000 each year worldwide. It can occur at any age but is most often diagnosed between the ages of 25 and 60. Men and women are affected about equally.

Types of Achalasia

• Type I (classic achalasia): the oesophagus has very little or no contraction along its length.
• Type II (achalasia with oesophageal compression): there is pressurisation along the whole length of the oesophagus during swallowing. This subtype generally responds well to all the standard treatments.
• Type III (spastic achalasia): there are premature, spastic contractions of the oesophageal muscle. This subtype is often more difficult to treat and may respond better to a longer myotomy.

Your gastroenterologist will usually tell you which subtype you have based on the manometry report. The subtype is one of the most important pieces of information guiding the choice of treatment.

Why Heller Myotomy Is Performed

A Heller myotomy is a surgical operation in which the tight muscle fibres of the lower oesophageal sphincter, and a small portion of the muscle of the lower oesophagus and upper stomach, are deliberately cut. Cutting these muscle fibres releases the obstruction so that food and liquid can pass into the stomach more easily. The mucosa — the inner lining of the oesophagus — is left intact.

The operation is named after Ernst Heller, a German surgeon who first described the technique in 1913. The modern version is performed using keyhole (laparoscopic) surgery and is almost always combined with a partial fundoplication (an anti-reflux wrap) to reduce the risk of acid reflux after the muscle is cut.

Heller myotomy is performed because:

• Achalasia does not go away on its own and tends to worsen over time.
• Untreated achalasia leads to progressive dilation of the oesophagus, severe weight loss, malnutrition, and an increased long-term risk of certain oesophageal complications.
• Surgical myotomy provides durable, long-lasting symptom relief in the majority of patients.
• For many patients, particularly younger and fitter ones, a definitive treatment is often preferred over repeated less invasive procedures.

The goal of treatment in achalasia is not to cure the underlying nerve problem — this cannot currently be reversed — but to relieve the obstruction at the lower sphincter so that swallowing becomes possible and comfortable again.

How Achalasia Is Diagnosed

If you are reading this, you have likely already been through some or all of these tests. They are described briefly here so you understand what the results mean and why they shape treatment decisions.

Barium Swallow

A barium swallow is an X-ray test in which you drink a thick, white liquid containing barium while X-ray images are taken. In achalasia, the test classically shows a dilated oesophagus that narrows to a thin point at the bottom — described as a “bird’s beak” appearance. Barium is also seen to sit and pool above the tight sphincter rather than passing freely into the stomach. A timed version of the test (the timed barium swallow) is sometimes used both at diagnosis and during follow-up to measure how well the oesophagus empties.

Upper Endoscopy

An upper endoscopy involves passing a thin, flexible tube with a camera (an endoscope) into the oesophagus and stomach. This test is important not so much to diagnose achalasia as to rule out other causes of similar symptoms, particularly a tumour at the bottom of the oesophagus or top of the stomach — a condition called pseudoachalasia, which can look very similar but requires different treatment.

High-resolution Oesophageal Manometry

Manometry is the definitive test for achalasia. A thin tube with multiple pressure sensors is passed through the nose into the oesophagus, and you are asked to swallow small sips of water while the pressures along the oesophagus are recorded. In achalasia, manometry shows an absent or abnormal peristaltic wave and incomplete relaxation of the lower oesophageal sphincter when swallowing. The pattern of the readings also identifies the subtype (Type I, II, or III).

Who Is a Candidate for Heller Myotomy?

Heller myotomy is generally considered for patients who have:

• A confirmed diagnosis of achalasia on manometry
• Symptoms that interfere meaningfully with eating, weight, or daily life
• An ability to tolerate general anaesthesia and laparoscopic surgery
• A preference for, or clinical indication for, a durable treatment rather than a repeated less invasive procedure

Doctors typically discuss Heller myotomy as one of the main options for younger and fitter patients with Type I or Type II achalasia. For Type III (spastic) achalasia, current guidelines from the American College of Gastroenterology (ACG) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) often favour per-oral endoscopic myotomy (POEM) because a longer myotomy along the body of the oesophagus is needed.

Heller myotomy may not be the preferred option for patients who:

• Are not medically fit for general anaesthesia or laparoscopic surgery
• Have had multiple previous abdominal surgeries that may make laparoscopy difficult
• Have very advanced (end-stage) achalasia with a severely dilated, sigmoid-shaped oesophagus, where the oesophagus itself may no longer empty even after the sphincter is opened — these patients sometimes need oesophagectomy (removal of the oesophagus), although this is considered a last resort

The decision of who is a good candidate is individualised. Your surgeon will review your manometry, barium swallow, endoscopy, general health, and personal preferences before discussing an approach.

Alternatives to Heller Myotomy

Several other treatments are used for achalasia. Each has a different profile of effectiveness, durability, invasiveness, and side effects. The choice between them is a clinical decision made with your gastroenterologist and surgeon.

Per-Oral Endoscopic Myotomy (POEM)

POEM is a newer technique that achieves the same goal as Heller myotomy — cutting the tight muscle of the lower oesophageal sphincter — but does so endoscopically, with no skin incisions at all. An endoscope is passed through the mouth, a small tunnel is created in the wall of the oesophagus, and the muscle is cut from the inside.

POEM has gained acceptance rapidly over the last decade. Major societies, including ACG and SAGES, now describe POEM as comparable to laparoscopic Heller myotomy in terms of symptom relief, with the caveat that POEM tends to produce more acid reflux after surgery because no anti-reflux wrap is added. For Type III achalasia, POEM is often described as the preferred option because the length of the myotomy can be tailored. POEM requires a specifically trained endoscopist and is performed at centres with experience in the technique.

Pneumatic Dilation

In pneumatic dilation, a large balloon is passed through the mouth into the lower oesophagus and inflated forcefully to stretch and tear the muscle fibres of the lower sphincter. The procedure is done under sedation, usually with X-ray guidance, and does not require any surgical incisions.

Pneumatic dilation can produce good symptom relief, particularly for Type II achalasia. Many patients need more than one dilation over time as the effect wears off. The main risk is perforation (a tear in the oesophagus), which occurs in a small percentage of cases and may need surgical repair. Pneumatic dilation is sometimes called “graded” or “serial” dilation because larger balloons are used in successive sessions if needed.

Botulinum Toxin (Botox) Injection

Botulinum toxin can be injected during endoscopy directly into the lower oesophageal sphincter. The toxin paralyses the muscle temporarily, allowing it to relax. The effect typically lasts six to twelve months and then wears off, requiring repeat injections.

Botulinum toxin injection is less effective and less durable than Heller myotomy, POEM, or pneumatic dilation. Guidelines generally describe it as most useful for patients who are not fit for more definitive treatment, such as elderly patients with significant other medical problems, or as a temporary measure. Repeated injections can also cause scarring that may make later surgery more difficult, which is something your surgeon will take into account.

Medications

Certain medications — calcium channel blockers and long-acting nitrates — can relax the lower oesophageal sphincter and provide modest symptom relief. They are generally considered the least effective option and are usually reserved for patients who cannot have any of the other treatments. Side effects such as headache, dizziness, and low blood pressure are common.

Surgical Approaches to Heller Myotomy

Heller myotomy is almost always performed using minimally invasive (keyhole) surgery today. The open approach is rarely used except in unusual circumstances.

Laparoscopic Heller Myotomy

This is the standard approach. Five or six small incisions, each about a centimetre long, are made on the upper abdomen. A camera and long thin instruments are passed through these incisions, the stomach is gently retracted, and the muscle fibres at the junction of the oesophagus and stomach are carefully divided. A partial anti-reflux wrap (a Dor or Toupet fundoplication) is then constructed using a portion of the stomach.

Robotic-Assisted Heller Myotomy

In robotic-assisted Heller myotomy, the surgeon uses a robotic system to control the surgical instruments. The robot offers three-dimensional vision and very precise instrument movement, which some surgeons find useful in this delicate operation. The risk of accidentally perforating the oesophageal mucosa — one of the main intraoperative concerns — may be lower in robotic-assisted procedures in some studies, although overall results are similar to standard laparoscopy. Availability depends on the hospital and the surgeon’s training.

Open Heller Myotomy

Open surgery, through a larger incision in the upper abdomen or the left chest, was the standard before laparoscopy became widespread. It is now used very rarely, usually only when laparoscopic surgery is not possible because of previous extensive surgery or anatomical concerns.

Preparing for Heller Myotomy

The preparation for Heller myotomy is similar to that for other elective upper abdominal surgeries, with a few additions specific to the oesophagus.

Pre-operative Tests

You will usually have:

• Blood tests, including a complete blood count, kidney and liver function tests, and clotting tests
• An ECG (electrocardiogram), particularly if you are older or have heart concerns
• A chest X-ray
• Anaesthesia review to assess fitness for general anaesthesia
• Confirmation that your diagnostic workup (manometry, endoscopy, barium swallow) is complete

Diet Before Surgery

Because the oesophagus may be dilated and contain retained food, your surgeon may ask you to follow a liquid-only diet for one to three days before surgery, and to fast completely for a longer period than usual on the day of surgery. This reduces the risk of food being present in the oesophagus during anaesthesia, where it could be inhaled into the lungs.

Medications

You will be asked to share a list of all medications and supplements you take. Some medications — particularly blood thinners, certain diabetes medications, and some supplements — may need to be stopped or adjusted before surgery. Your surgical and anaesthesia team will give you specific instructions.

Other Preparations

Smoking should be stopped as far in advance of surgery as possible, ideally several weeks before, to reduce respiratory complications. If you have any active infection (chest infection, urinary infection, dental infection), tell your team, as surgery may need to be postponed. Plan for help at home during the first one to two weeks of recovery.

What Happens During Heller Myotomy

The operation typically takes one to two hours under general anaesthesia.

1. Anaesthesia and positioning. You are given general anaesthesia so that you are asleep and feel nothing. You are positioned on the operating table, usually with the head of the bed raised.
2. Access. Five or six small (about one centimetre) incisions are made in the upper abdomen. Carbon dioxide gas is gently introduced into the abdomen to create space to work. A camera (laparoscope) is inserted through one port and instruments through the others.
3. Exposure. The surgeon gently lifts the left lobe of the liver to expose the junction where the oesophagus meets the stomach.
4. The myotomy. The outer muscle layer at the lower oesophagus and the very top of the stomach is carefully divided lengthwise — typically about six centimetres up the oesophagus and two to three centimetres down onto the stomach. The mucosa (the inner lining) is left intact. This is the most delicate part of the operation because the mucosa is thin and can be perforated.
5. The anti-reflux wrap (fundoplication). Because the muscle that prevents acid reflux has just been cut, a partial wrap is created using the top of the stomach. Two types of wrap are commonly used: a Dor (anterior) wrap covers the front of the cut muscle, and a Toupet (posterior) wrap covers the back. Either type is partial — not a full wrap — because a full wrap could re-create obstruction in an oesophagus that no longer has normal peristalsis.
6. Closure. The instruments are removed, the gas is released, and the small incisions are closed with sutures, clips, or surgical glue.

An intraoperative endoscopy may be performed at the end of surgery to check that the myotomy is adequate and that there is no mucosal perforation.

Recovery and Healing

In Hospital

Most patients stay in hospital for one to three days after a laparoscopic Heller myotomy. On the day of surgery, you will be in some pain at the incision sites and possibly at the tip of the shoulder (referred pain from the gas used during laparoscopy). Pain is managed with regular pain medication.

On the day after surgery, a contrast swallow study (a small X-ray test in which you drink a contrast liquid) is sometimes performed to confirm that the oesophagus is intact and that there is no leak. Once this is confirmed, you can start sips of water, progressing to clear liquids.

Diet After Surgery

Diet progression typically follows a careful sequence:

• Days 1–2: clear liquids only
• Days 3–7: full liquids (smoothies, soups, yoghurt without lumps)
• Weeks 2–4: soft, easy-to-swallow foods (mashed vegetables, soft pasta, scrambled eggs, soft fish)
• From about week 4 onwards: gradual reintroduction of regular food, chewing well and avoiding large, dry, or fibrous chunks early on

Your surgeon will give you a specific diet plan. The progression is meant to give the cut muscle time to heal and to avoid pressure on the wrap.

Activity

You can usually walk on the day of surgery and resume most light activities within a week or two. Lifting heavy weights (more than about five kilograms) is usually avoided for four to six weeks to allow the abdominal wall to heal. Most patients return to desk-based work within two to three weeks, and to more physical work within four to six weeks. Driving can be resumed when you are off strong pain medication and can perform an emergency stop without discomfort.

Symptom Improvement

Risks and Complications

Heller myotomy is a well-established operation with a good safety record in experienced hands, but as with any surgery there are risks. Your surgeon will discuss these in detail before you sign consent. The main risks include:

Intraoperative Complications

• Mucosal perforation: a small tear in the inner lining of the oesophagus during the myotomy. This is the most common intraoperative complication. When recognised at the time of surgery, it is repaired with sutures during the same operation and usually heals without long-term consequences.
• Bleeding: typically minor and controllable during surgery.
• Injury to nearby structures such as the vagus nerve, spleen, or liver. These are uncommon.

Early Post-operative Complications

• Leak from an unrecognised perforation: rare but serious; this is the reason for the contrast swallow test before starting oral intake.
• Wound infection at one of the port sites.
• Chest infection or atelectasis (small areas of lung collapse), particularly in smokers.
• Blood clots in the legs (DVT) or lungs (PE). Preventive measures such as early walking and blood thinner injections are used.

Long-term Complications

• Acid reflux: the most common long-term issue. The partial fundoplication is designed to reduce this, but some patients still develop reflux and may need long-term acid-suppressing medication.
• Persistent or recurrent difficulty swallowing: if the myotomy is incomplete, scarring forms, or the wrap is too tight, swallowing problems can return. Further treatment such as endoscopic dilation or a repeat procedure may be needed.
• Heartburn-related complications: long-standing reflux can lead to oesophagitis or, rarely, Barrett’s oesophagus, which is why follow-up endoscopy is important.

Life After Heller Myotomy

For most patients, a Heller myotomy provides good, long-lasting relief of swallowing difficulty. Studies suggest that the majority of patients have meaningful improvement that persists for many years.

Eating Habits

Even after a successful myotomy, the oesophageal body usually still does not have normal peristalsis. This means food relies largely on gravity to reach the stomach. Most patients find it helpful to:

• Eat slowly and chew food thoroughly
• Take small bites
• Drink fluids with meals to help wash food down
• Sit upright while eating and stay upright for at least 30 to 60 minutes after meals
• Avoid eating large meals close to bedtime
• Notice which foods are easy and which are difficult (dry meats, soft bread, and large clumps of rice are common offenders)

Acid Reflux Management

Even with the anti-reflux wrap, some patients have acid reflux after surgery. Doctors often recommend periodic monitoring — sometimes with a 24-hour acid (pH) study — especially if heartburn symptoms develop. Acid-suppressing medications such as proton pump inhibitors may be prescribed. Because long-standing reflux can in rare cases cause changes in the oesophageal lining, most centres recommend periodic surveillance endoscopy.

Follow-up and Surveillance

Achalasia is associated with a slightly increased long-term risk of oesophageal cancer, even after successful treatment. The risk is small, but most guidelines suggest periodic endoscopic surveillance after several years of diagnosis. The exact interval is something your gastroenterologist will plan with you.

Recurrence of Symptoms

If swallowing difficulty returns months or years after surgery, this should not be ignored. It can be caused by scarring at the myotomy site, a too-tight wrap, or progression of the underlying disease. Repeat tests — manometry, barium swallow, endoscopy — will usually clarify the cause, and further treatment options include endoscopic dilation, POEM, or revision surgery in selected cases.

Achalasia in Children

Achalasia is far less common in children than in adults, but it does occur. The diagnosis is often delayed because the symptoms — difficulty swallowing, regurgitation, chest pain, weight loss, recurrent chest infections, or failure to thrive — can be mistaken for other conditions such as gastro-oesophageal reflux, asthma, or eating problems.

The diagnostic approach in children is the same as in adults: barium swallow, endoscopy, and high-resolution manometry. Manometry in children may need to be performed under sedation depending on age and cooperation.

Treatment options in paediatric achalasia are essentially the same as in adults — pneumatic dilation, laparoscopic Heller myotomy, and POEM. Heller myotomy has historically been the most commonly used definitive treatment in children, with good long-term outcomes reported in the majority of children operated on. POEM is increasingly being used in paediatric centres with appropriate expertise. Botulinum toxin injection is used less often in children because the effect is temporary and repeated procedures under anaesthesia are not ideal.

Children who have achalasia in the context of a rarer syndrome (such as Allgrove syndrome, sometimes called Triple A syndrome, which involves achalasia, adrenal insufficiency, and reduced tear production) need additional evaluation and management of the associated conditions. Long-term follow-up into adulthood is important for all children treated for achalasia.

Frequently Asked Questions

Will Heller myotomy cure my achalasia?

Heller myotomy treats the obstruction at the lower oesophageal sphincter very effectively, but it does not cure the underlying nerve problem in the oesophagus. The peristaltic wave does not return after surgery. What does change is that food and liquid can now pass into the stomach much more easily, so swallowing becomes possible and comfortable again. For most patients, this means a major and lasting improvement in quality of life.

How do I choose between Heller myotomy, POEM, and pneumatic dilation?

This is a clinical decision that depends on several factors: your achalasia subtype on manometry, your age and overall fitness, your preferences about durability versus invasiveness, what your local centre is experienced in, and any previous treatments you have had. Major societies describe all three as effective options, with POEM often favoured for Type III achalasia, Heller myotomy as a robust option with a well-established track record, and pneumatic dilation as the least invasive procedural option. Your gastroenterologist and surgeon are best placed to discuss which fits your situation.

Can I eat normally after surgery?

In time, most patients can eat a wide range of foods, but eating habits usually change permanently. Eating more slowly, chewing thoroughly, and avoiding very dry or large pieces of food typically become long-term habits. Large heavy meals and eating just before lying down are best avoided.

Will I have acid reflux after surgery?

Some degree of acid reflux is possible even with the partial fundoplication. Most patients who develop reflux can manage it with lifestyle adjustments and acid-suppressing medication. Reflux is one of the main reasons for long-term follow-up after Heller myotomy.

What if my symptoms come back?

If swallowing difficulty or regurgitation return, see your gastroenterologist. Tests will usually clarify the cause, and further treatment options exist, including endoscopic dilation of the myotomy site, POEM, or revision surgery in selected cases.

Is achalasia hereditary?

Achalasia is rarely inherited. Most cases occur sporadically without a family history. A small number of cases are associated with specific genetic syndromes (such as Allgrove syndrome), but these are uncommon.

Does achalasia increase the risk of cancer?

Long-standing achalasia is associated with a small increase in the long-term risk of oesophageal cancer compared with the general population. The risk is low but is part of the reason that periodic surveillance endoscopy is generally recommended after several years.

How soon can I travel after surgery?

Most patients can travel for short distances within a couple of weeks of surgery, once they are eating comfortably and pain is well controlled. Long-distance air travel is usually delayed for a few weeks because of the small additional risk of blood clots. Your surgeon will give you specific advice based on your recovery.

Conclusion

Achalasia is an uncommon but treatable condition. Although the underlying nerve damage cannot be reversed, the obstruction it causes can be relieved very effectively with modern treatments. Heller myotomy, performed laparoscopically and combined with a partial fundoplication, has been a mainstay of treatment for decades and continues to provide durable symptom relief for the majority of patients. Newer options such as POEM and well-established alternatives such as pneumatic dilation expand the choices available, and the decision about which to use is best made together with a gastroenterologist and surgeon experienced in achalasia.

If you are planning treatment, take the time to understand your manometry subtype, ask your team why a particular approach is being suggested for you, and clarify what the recovery and long-term follow-up will look like. With careful treatment and ongoing follow-up, most people with achalasia regain the ability to eat comfortably and live well.