Esophageal myotomy

Last revised by Rohit Sharma on 2 Apr 2024

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°

An alternative procedure, per-oral esophageal myotomy (POEM), is increasing in use in some centers.

Radiographic features


On contrast swallow examination, there may be characteristic "ballooning" of the distal esophagus after a myotomy (50%), as the esophagus bulges through the myotomy 3-4.

History and etymology

The first successful cardiomyotomy for achlasia was performed by the German surgeon Ernest Heller in 1913 5.

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