Esophageal myotomy

Esophageal myotomy (or Heller myotomy) is a procedure that can be performed to treat a lower esophageal sphincter that fails to relax (e.g. achalasia). The procedure involves a longitudinal incision of the distal esophageal musculature to break the sphincter tone.

A fundoplication wrap can be performed to restore some patency to the lower esophageal sphincter. A section of the gastric fundus is wrapped around the gastro-esophageal sphincter to mechanically apply some tone to the junction. There are several variations, including

• Nissen fundoplication: the gastric fundus is passed behind the distal 6 cm of the esophagus and a 360° wrap is performed by pulling some of the fundus anteriorly as well and attaching the two ends anteriorly
• Toupet fundoplication: Similar to a Nissen, but a 270° wrap
• Dor fundoplication: the fundus is pulled anteriorly <180°

A more recent technique of per-oral esophageal myotomy (POEM) is increasing in use in some centers.

Radiographic features

Fluoroscopy

On contrast swallow examination, there may be characteristic "ballooning" of the distal esophagus after a myotomy (50%), as the esophagus bulges through the myotomy .

History and etymology

The first successful cardiomyotomy for achlasia was performed by the German surgeon Ernest Heller in 1913 .