Surgical Treatment Of Esophageal Achalasia

Publication Date: May 1, 2011


Diagnosis and Preoperative Workup

Patients with suspected achalasia should undergo a barium esophagram, an upper endoscopy, and esophageal manometry to confirm the diagnosis. (Moderate, Strong)


Pharmacotherapy plays a very limited role in the treatment of achalastic patients and should be used in very early stages of the disease, temporarily prior to more definitive treatments, or for patients who fail or are not candidates for other treatment modalities. (High, Strong)

Botulinum toxin injections

Botulinum toxin injection can be administered safely, but its effectiveness is limited especially in the long term. It should be reserved for patients who are poor candidates for other more effective treatment options such as surgery or dilation. (High, Strong)

Endoscopic Dilation

Among nonoperative treatment techniques endoscopic dilation is the most effective for dysphagia relief in patients with achalasia but is also associated with the highest risk of complications. It should be considered in selected patients who refuse surgery or are poor operative candidates. (High, Strong)

Esophageal stents

The use of esophageal stents cannot be recommended for the treatment of achalasia. (Low, Strong)

Surgical Treatment of Achalasia

Laparoscopic myotomy can be performed safely and with minimal morbidity in appropriately selected patients by appropriately trained surgeons and leads to dysphagia control and improved quality of life in the majority of patients. (High, Strong)
A relatively small proportion of patients, however, will experience recurrent symptoms in the long term often associated with postoperative reflux.
Prior endoscopic treatment for achalasia may be associated with higher myotomy morbidity, but the literature is inconclusive. A careful approach by an experienced team is advisable. (Low, Strong)

Surgery versus other treatment modalities

Laparoscopic myotomy with partial fundoplication provides superior and longer-lasting symptom relief with low morbidity for patients with achalasia compared with other treatment modalities and should be considered the procedure of choice to treat achalasia. (High, Strong)

Type of surgical approach

Transabdominal is superior to transthoracic esophageal myotomy due to improved postoperative reflux control by the addition of an antireflux procedure, performed only when the myotomy is done transabdominally. Laparoscopic myotomy offers advantages regarding postoperative pain, length of stay, and morbidity compared to open myotomy. The laparoscopic approach also allows routine incorporation of an antireflux procedure after myotomy, and is associated with the lowest patient morbidity, and therefore, is the procedure of choice for the surgical treatment of achalasia in most patients. (Moderate, Strong)
Compared with laparoscopy, robotic assistance has been demonstrated to decrease the rate of intraoperative esophageal mucosal perforations, (Low, Weak)
but no clear differences in postoperative morbidity, symptom relief, or long-term outcomes have been described. Further study is necessary to better establish the role of robotic myotomy.


Patients who undergo a myotomy should also have a fundoplication to prevent postoperative reflux and minimize treatment failures. (High, Strong)
The optimal type of fundoplication is debated (posterior vs. anterior), but partial fundoplication should be favored over total fundoplication, as it is associated with decreased dysphagia rates and similar reflux control. (Low, Weak)
Additional evidence is needed to determine which partial fundoplication provides the best reflux control after myotomy.
The length of the esophageal myotomy should be at least 4 cm on the esophagus and 1-2 cm on the stomach. (Very Low, Weak)

Treatment options after failed myotomy

Endoscopic Botulinum toxin treatment can be applied safely and with equal effectiveness before or after myotomy, (Low, Weak)
but endoscopic balloon dilation after myotomy is currently considered hazardous by most experts and should be avoided. (Low, Weak)
Repeat myotomy may be superior to endoscopic treatment and should be undertaken by experienced surgeons. (Low, Strong)
Esophagectomy should be considered in appropriately selected patients after myotomy failure. (Very Low, Weak)

Epiphrenic Diverticulae

Epiphrenic diverticula should be treated surgically when symptomatic. Given their frequent association with achalasia, esophageal manometry should be pursued to confirm the diagnosis of achalasia when they are identified. A myotomy at the opposite side of the diverticulum that goes beyond the distal extent of the diverticulum should be performed when achalasia is present. In this situation, concomitant diverticulectomy may be indicated based on the size of the diverticulum. When diverticula are not resected, endoscopic surveillance is advised. The optimal approach for their treatment needs further study, and surgeons should be aware of the relatively high incidence of postoperative leaks. (Very Low, Weak)

Recommendation Grading




Surgical Treatment Of Esophageal Achalasia

Authoring Organization

Publication Month/Year

May 1, 2011

Document Type


External Publication Status


Country of Publication


Document Objectives

The guidelines for the surgical treatment of esophageal achalasia are a series of systematically developed statements to assist surgeon (and patient) decisions about the appropriate use of minimally invasive techniques for the treatment of achalasia in specific clinical circumstances

Target Patient Population

Patients with esophageal achalasia

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D013502 - General Surgery, D013903 - Thoracic Surgery, D004724 - Endoscopy, D004931 - Esophageal Achalasia, D010535 - Laparoscopy


Esophageal Achalasia, achalasia

Source Citation

Supplemental Methodology Resources

Systematic Review Document