Hindawi Publishing Corporation

Gastroenterology Research and Practice

Volume 2013, Article ID 708327, 5 pages
http://dx.doi.org/10.1155/2013/708327

Review Article
Surgical Treatment for Achalasia of the Esophagus:
Laparoscopic Heller Myotomy
Gonzalo Torres-Villalobos1,2 and Luis Alfonso Martin-del-Campo1
1

Department of Surgery, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga No. 15,
Colonia Seccion XVI, 14000 Tlalpan, Mexico, DF, Mexico
2
Experimental Surgery Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran,
Vasco de Quiroga No. 15, Colonia Seccion XVI, 14000 Tlalpan, Mexico, DF, Mexico
Correspondence should be addressed to Gonzalo Torres-Villalobos; [email protected]
Received 7 October 2013; Accepted 27 October 2013
Academic Editor: Antoni Castells
Copyright 2013 G. Torres-Villalobos and L. A. Martin-del-Campo. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Achalasia is an esophageal motility disorder that leads to dysphagia, chest pain, and weight loss. Its diagnosis is clinically suspected
and is confirmed with esophageal manometry. Although pneumatic dilation has a role in the treatment of patients with achalasia,
laparoscopic Heller myotomy is considered by many experts as the best treatment modality for most patients with newly diagnosed
achalasia. This review will focus on the surgical treatment of achalasia, with special emphasis on laparoscopic Heller myotomy. We
will also present a brief discussion of the evaluation of patients with persistent or recurrent symptoms after surgical treatment for
achalasia and emerging technologies such as LESS, robot-assisted myotomy, and POEM.

1. Introduction
Achalasia is a primary esophageal motility disease that usually presents with progressive dysphagia, chest pain, regurgitation, and weight loss. Its etiology is not fully understood,
and its incidence is approximately 1 to 3 cases of 100,000 persons per year [1].
Although achalasia can be suspected using clinical, radiographic, and endoscopic information, definite diagnosis can
only be made using esophageal manometry [2], which shows
the absence of esophageal motility and in most cases inappropriate lower esophageal sphincter (LES) relaxation.
High-resolution manometry can be used to further study
esophageal motility in patients with achalasia by categorizing
patients into 3 subtypes that can predict patient response to
endoscopic or surgical treatment [3].
Treatment for patients with achalasia focuses on symptoms improvement. Endoscopic and surgical approaches
for treating achalasia seek to overcome esophageal outflow obstruction while trying to prevent the development of
gastroesophageal reflux disease (GERD) and its associated
complications [1, 4, 5]. This review will focus on the surgical

treatment of achalasia with special emphasis on laparoscopic

Heller myotomy.

2. Surgical Treatment of Achalasia:

Is Laparoscopy Better?
The main objective in surgery for achalasia is the disruption
of the LES muscular fibers [6, 7]. The first description of an
esophageal myotomy for achalasia was in 1913 by Heller [8], in
which both anterior and posterior muscle fibers were divided.
A modified procedure currently known as Heller myotomy is
the longitudinal division of the anterior muscle fibers and has
become the standard surgical approach for achalasia [4].
Myotomy can be safely performed using open abdominal
and thoracic approaches, and for more than two decades,
it has also been done using laparoscopy and thoracoscopy
[6]. A meta-analysis by Campos et al. [9] showed that both
the thoracic and the abdominal open approaches lead to
similar symptom improvement, but the former is associated
with twice more GERD symptoms after surgery. When laparoscopy and thoracoscopy are compared, laparoscopy has
shown better symptom improvement rates and lower GERD

Gastroenterology Research and Practice

Figure 1: Blunt dissection for myotomy.

Figure 2: Myotomy extent proximal and distal to the LES.

incidence. This difference could be attributed to the fundoplication routinely performed in the laparoscopic group. There
are no differences in postoperative complications between
these surgical options, but laparoscopy has shown to reduce
hospital stay, have less bleeding, have lower analgesic use, and
allow for shorter time of return to normal activities. Therefore, laparoscopic myotomy is now considered the surgical
procedure of choice for treating achalasia.

3. Laparoscopic Myotomy: Surgical Technique

The patient is placed on the operating table in the supine
position, and pneumoperitoneum is established followed by
placement of 3 to 4 additional trocars using direct visualization.
Dissection can be started by proximal mobilization of
the gastric fundus to prepare for a fundoplication as short
vessels are divided using harmonic scalpel. If a hiatal hernia is
found, it should be reduced and an adequate intra-abdominal
esophagus length must be obtained. Although it has been
shown that there may be variations between the endoscopic
location of the squamous columnar junction and the LES
[10], endoscopy is used to verify completion of the myotomy
by identifying a wide open GE junction with no visible
crossing residual muscle fibers [6, 11]. The esophagogastric
junction (EGJ) is exposed for 6 to 8 cm proximally, and
the myotomy is performed longitudinally in the anterior
esophageal axis (Figure 1) using blunt dissection, electric
hook, scissors, or the harmonic scalpel. Caution must be
taken to avoid injury to the esophageal mucosa, especially
when using hook cautery or harmonic scalpel because a
burned mucosa may perforate in the postoperative period.
The procedure is completed by performing a partial anterior
(Dor) or a posterior (Toupet) fundoplication.
3.1. Myotomy. The best place to start the myotomy is about
2 cm above the gastroesophageal junction, where the submucosal plane is easier to find. Essential to the operation is the
length of the myotomy (Figure 2). Some recommendations
advocate for 4 to 8 cm proximal and 0.5 to 2 cm distal
myotomy [6], which have been associated to lower dysphagia
rates and LES resting pressures. Oelschlager et al. have shown
that when the distal myotomy in the stomach is increased
to 3 cm, both dysphagia rates and LES resting pressures

Figure 3: Creation of an anterior partial fundoplication after myotomy.

are further reduced, with no associated increase in pyrosis,

regurgitation, or thoracic pain [12].
3.2. Fundoplication. When a fundoplication is not performed
after myotomy, 47% to 100% of patients have postoperative
pH-metry confirmed GERD [13, 14]. Some of these patients
progress to erosive esophagitis, esophageal stenosis, and Barretts esophagus [7].
On the other hand, given the total absence of esophageal
peristalsis in patients with achalasia, the risk of performing
a total fundoplication is to have persistent or recurrent dysphagia [5]. This was demonstrated in a prospective study
that compared total (Nissen) versus partial anterior (Dor)
fundoplication after Heller myotomy; it showed equal GERD
control but higher dysphagia rate (15% versus 2.8%) for the
total fundoplication group after 5 years of followup [15].
Therefore, partial fundoplication is the procedure of
choice after Heller myotomy (Figure 3). The differences
between anterior 180 (Dor) and posterior 270 (Toupet) fundoplication were recently studied in a multicentric, randomized controlled trial that showed no subjective differences
in dysphagia or reflux between both groups but did show a
higher (not statistically significant) abnormal 24-hour pHmetry (41.7% versus 21%) for the Dor group [16]. Current
guidelines state that further high quality is needed in order
to find the ideal antireflux procedure after myotomy [6].
We are currently running a prospective, randomized trial
comparing Dor versus Toupet fundoplication and evaluating

Gastroenterology Research and Practice

postoperative pH-metry and high-resolution manometry to
further solve this question.

4. Complications after Surgical Treatment

About 6.3% of the patients who are treated surgically for
achalasia have postoperative complications, and only 0.7% of
them are clinically relevant [6]. Esophageal perforation may
occur in about 7% of the patients [9], but patients who have
been previously treated with endoscopic dilation or botulin
toxin may have higher perforation rates [6].
Conversion to an open procedure is not frequent in experienced centers and is usually due to esophageal perforation
or bleeding. Mortality from laparoscopic Heller myotomy is
0% in most series [4].

5. Emerging Technologies
5.1. Laparoendoscopic Single Site Surgery (LESS). LESS is a
surgical approach that uses a single port generally placed
in the umbilical scar. There are few reports regarding LESS
Heller myotomy. A single center experience report of 66
patients showed that a LESS approach can offer similar symptomatic response and patient satisfaction rates to those of
the traditional laparoscopic approach, at the cost of longer
operative times (117 versus 93 minutes) and the need for extra
port placement in 16% of patients [17].
The authors of this report conclude that LESS Heller
myotomy is feasible, safe, and effective and is cosmetically
superior due to a minimal umbilical scar. The same group
has recently published its updated experience with the LESS
Heller myotomy and concluded that surgeons experienced in
the conventional laparoscopic myotomy can quickly attain
proficiency with this novel approach [18]. To this date, the
only advantage seems to be cosmetic.
5.2. Robot-Assisted Myotomy. Among the advantages of
robotic surgery are improved dexterity and a high quality
three-dimensional view of the procedure [19]. The first
published experience of robot-assisted myotomy reported on
54 procedures, with no esophageal perforation and93% of the
patients reporting dysphagia improvement after a short-term
followup [20].
The largest reported series is a retrospective analysis
of 2,683 cases, including 2,116 laparoscopic and 149 robotassisted myotomies. There were no differences regarding
morbidity, mortality, hospital stay, or readmission rates when
both approaches were compared. Nevertheless, the robotic
approach was associated with a higher cost [21].
5.3. Per Oral Endoscopic Myotomy (POEM). Ortega et al. first
described a less invasive endoscopic approach for achalasia in
1980 [22], but it was abandoned for almost 3 decades because
of concerns regarding the risk of directly incising esophageal
mucosa [23]. Recently, there has been a large interest in
modified versions of this technique that are based on the
creation of an esophageal submucosal tunnel approximately
13 cm proximal to the EGJ to further create a myotomy of
the inner circular esophageal muscle fibers [5]. There have
been many variations in the technique, including many

3
different myotomy lengths and circular plus longitudinal fiber
myotomy.
When comparing POEM perioperative results against
laparoscopic myotomy, a nonrandomized trial showed that
POEM is associated with less blood loss (<10 versus 50 ml,
< 0.001) and shorter operative time (113 versus 124 min,
< 0.05) at the cost of higher pain scores on day 2 with no
differences regarding complication rates or length of stay [24].
Inoue et al. have performed this procedure more than 100
times in humans and have reported significant improvement
in dysphagia and up to 70% reduction in LES resting pressure
[25]. A recent report found 82% dysphagia remission after
POEM on a 12-month followup [26]. Another nonrandomized prospective study states that POEM is equally effective
for dysphagia relief in the short-term followup [27]. Up
to 10% of patients who undergo POEM have pneumoperitoneum after the procedure [28]. One of the main concerns
of this procedure is that an antireflux procedure cannot be
performed, and objectively confirmed GERD rates after
POEM are 46% [29].
Although a randomized clinical trial (POEM rcpmt)
that will compare POEM versus laparoscopic myotomy is
currently recruiting patients, there are currently no high
quality evidence and enough followup to endorse POEM as a
standard approach. Guidelines for treating achalasia consider
POEM as being in its infancy and state that further experience
is needed before recommendations can be provided regarding its role in patients with achalasia [6].

6. Outcomes after Surgical Treatment

89% (77% to 100%) of patients report symptom improvement
after laparoscopic Heller myotomy [9] with satisfaction rates
over 90% and associated global improvement in quality of
life indicators [6]. Long-term followup (10 years) shows that
symptom and quality of life improvement are maintained
[30].
Very long-term followup by Csendes et al. shows that
failure rates after surgical treatment for achalasia are 7% after
10 years and 35% after 30 years of followup. The authors of this
report conclude that this may be due to a progressive increase
in esophageal exposure to abnormal gastric reflux, which they
demonstrated using pH-metry [31].
Risk factors for lower success rates after surgical treatment are severe preoperative dysphagia, low LES pressures,
severe esophageal dilation, and previous endoscopic dilation or botulin toxin treatment [6]. Using high-resolution
manometry Pandolfino et al. created a new system that classifies achalasia in three types [3]. This system has shown
to predict the success rates for patients undergoing Heller
myotomy, being 85.4% for type I, 95.3% for type II, and 69.4%
for type III [32].
It is known that patients with achalasia have higher
esophageal cancer incidence [33, 34], and this risk remains
even after surgical treatment [35]. Nevertheless, there are no
differences in survival between patients who have received
surgical treatment for achalasia and the general population
[36], and since 400 endoscopies must be performed to detect

4
1 cancer, there are currently no recommendations regarding
the endoscopic surveillance after Heller myotomy [2].

7. Evaluation and Treatment of the Patient

with Persistent or Recurrent Symptoms
The most common causes of failure after surgery are incomplete myotomy (33%) which is more frequently found in
the gastric myotomy, myotomy fibrosis (27%), fundoplication
disruption (13%), tight fundoplication (7%), and a combination of fibrosis and incomplete myotomy (20%) [9]. Outflow
obstruction, esophageal dilation, or sigmoid esophagus must
be ruled out using an esophagogram if dysphagia recurs.
Endoscopy can also show stenosis and obstructive lesions.
Manometry could show a persistently hypertensive LES [4].
Approximately 5% of patients will need another intervention [37]. There are multiple reports [38, 39] that support endoscopic dilation or reoperation as both safe and
effective options that can improve symptoms and avoid
esophagectomy. The Yokohama group reported on the use of
POEM in 10 patients with persistent or recurrent dysphagia
after Heller myotomy or pneumatic dilation and showed
symptomatic improvement and lower LES resting pressures
in the short-term followup [40]. Only a minority of patients
who show massive esophageal dilation will be candidates for
esophagectomy [41].

8. Conclusions
Medical treatment for achalasia is mainly reserved for
patients with very high surgical risk given its low longterm success for improving symptoms [42]. Although there
are randomized controlled trials [43] that have proven the
safety and efficacy of endoscopic dilation for achalasia, evidence ranging from expert opinion to meta-analysis supports
laparoscopic Heller myotomy as the best initial treatment for
most patients with achalasia [44, 45].
Laparoscopy has steadily positioned as the surgical
approach of choice to treat achalasia given its lower hospital
stay, less bleeding, less analgesic use, and shorter time
of return to normal activities when compared with open
approaches. Critical aspects of the laparoscopic Heller myotomy include obtaining an adequate length of intra-abdominal
esophagus, identification of the EGJ in order to perform a
complete proximal (5 cm) and distal (3 cm) myotomy, and
creation of a partial fundoplication.
Approximately 90% of patients will have symptom
improvement with Heller myotomy, and the majority of them
have no recurrence even after very long-term followup. Nevertheless, a minority of cases will have persistent or recurrent
symptoms, and one should thoroughly evaluate these patients
in order to adequately provide interventions such as pneumatic dilation or reoperation while reserving esophagectomy
for patients with very severe esophageal dilation.
Although technologies such as LESS and POEM are
emerging, their use is still under investigation, and there are
currently no recommendations that support their use outside
the research context.

Gastroenterology Research and Practice

References
[1] I. Gockel, G. Sgourakis, D. G. Drescher, and H. Lang, Impact of
minimally invasive surgery in the spectrum of current achalasia
treatment options, Scandinavian Journal of Surgery, vol. 100,
no. 2, pp. 7277, 2011.
[2] M. F. Vaezi, J. E. Pandolfino, and M. F. Vela, ACG clinical guideline: diagnosis and management of achalasia, American Journal
of Gastroenterology, vol. 108, no. 8, pp. 12381250, 2013.
[3] J. E. Pandolfino, M. A. Kwiatek, T. Nealis, W. Bulsiewicz, J. Post,
and P. J. Kahrilas, Achalasia: a new clinically relevant classification by high-resolution manometry, Gastroenterology, vol. 135,
no. 5, pp. 15261533, 2008.
[4] V. A. Williams and J. H. Peters, Achalasia of the esophagus: a
surgical disease, Journal of the American College of Surgeons,
vol. 208, no. 1, pp. 151162, 2009.
[5] B. Bello, F. A. Herbella, and M. G. Patti, Evolution of the minimally invasive treatment of esophageal achalasia, World Journal
of Surgery, vol. 35, no. 7, pp. 14421446, 2011.
[6] D. Stefanidis, W. Richardson, T. M. Farrell, G. P. Kohn, V.
Augenstein, and R. D. Fanelli, SAGES guidelines for the surgical treatment of esophageal achalasia, Surgical Endoscopy, vol.
26, no. 2, pp. 296311, 2012.
[7] D. L. Francis and D. A. Katzka, Achalasia: update on the disease
and its treatment, Gastroenterology, vol. 139, no. 2, pp. 369e1,
2010.
[8] E. Heller, Extramukose cardioplastik bein chronischen Cardiospasmus mit Dilatation des Oesophagus, Mitteilungen aus
Den Grenzgebieten Der Medizin Und Chirurgie, vol. 27, article
141, 1913.
[9] G. M. Campos, E. Vittinghoff, C. Rabl et al., Endoscopic and
surgical treatments for achalasia: a systematic review and metaanalysis, Annals of Surgery, vol. 249, no. 1, pp. 4557, 2009.
[10] A. Csendes, F. Maluenda, I. Braghetto, P. Csendes, A. Henriquez, and M. S. Quesada, Location of the lower oesophageal
sphincter and the squamous columnar mucosal junction in
109 healthy controls and 778 patients with different degrees of
endoscopic oesophagitis, Gut, vol. 34, no. 1, pp. 2127, 1993.
[11] M. Bloomston, P. Brady, and A. S. Rosemurgy, Videoscopic
Heller myotomy with intraoperative endoscopy promotes optimal outcomes, Journal of the Society of Laparoendoscopic
Surgeons/Society of Laparoendoscopic Surgeons, vol. 6, no. 2, pp.
133138, 2002.
[12] B. K. Oelschlager, L. Chang, C. A. Pellegrini et al., Improved
outcome after extended gastric myotomy for achalasia, Archives
of Surgery, vol. 138, no. 5, pp. 490497, 2003.

[13] D. Falkenback, J. Johansson, S. Oberg

et al., Hellers esophagomyotomy with or without a 360 floppy Nissen fundoplication for achalasia. Long-term results from a prospective randomized study, Diseases of the Esophagus, vol. 16, no. 4, pp. 284
290, 2003.
[14] W. O. Richards, A. Torquati, M. D. Holzman et al., Heller myotomy versus heller myotomy with dor fundoplication for achalasia: a prospective randomized double-blind clinical trial,
Annals of Surgery, vol. 240, no. 3, pp. 405415, 2004.
[15] F. Rebecchi, C. Giaccone, E. Farinella, R. Campaci, and M.
Morino, Randomized controlled trial of laparoscopic heller
myotomy plus dor fundoplication versus nissen fundoplication
for achalasia long-term results, Annals of Surgery, vol. 248, no.
6, pp. 10231029, 2008.
[16] A. Rawlings, N. J. Soper, B. Oelschlager et al., Laparoscopic
Dor versus Toupet fundoplication following Heller myotomy

Gastroenterology Research and Practice

[17]

[18]

[19]

[20]

[21]

[22]

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

for achalasia: results of a multicenter, prospective, randomizedcontrolled trial, Surgical Endoscopy, vol. 26, no. 1, pp. 1826,
2012.
L. Barry, S. Ross, S. Dahal et al., Laparoendoscopic singlesite Heller myotomy with anterior fundoplication for achalasia,
Surgical Endoscopy, vol. 25, no. 6, pp. 17661774, 2011.
S. B. Ross, K. Luberice, T. J. Kurian, H. Paul, and A. S. Rosemurgy, Defining the learning curve of laparoendoscopic singlesite Heller myotomy, American Journal of Surgery, vol. 79, no.
8, pp. 837844, 2013.
S. Undre, K. Moorthy, Y. Munz et al., Robot-assisted laparoscopic Heller cardiomyotomy: preliminary UK results, Digestive Surgery, vol. 21, no. 5-6, pp. 396400, 2004.
C. Galvani, M. V. Gorodner, F. Moser, M. Baptista, P. Donahue,
and S. Horgan, Laparoscopic Heller myotomy for achalasia
facilitated by robotic assistance, Surgical Endoscopy, vol. 20, no.
7, pp. 11051112, 2006.
A. Shaligram, J. Unnirevi, A. Simorov, V. M. Kothari, and D.
Oleynikov, How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy
for achalasia, Surgical Endoscopy, vol. 26, no. 4, pp. 10471050,
2012.
J. A. Ortega, V. Madureri, and L. Perez, Endoscopic myotomy
in the treatment of achalasia, Gastrointestinal Endoscopy, vol.
26, no. 1, pp. 810, 1980.
H. Inoue, K. M. Tianle, H. Ikeda et al., Peroral endoscopic
myotomy for esophageal achalasia: technique, indication, and
outcomes, Thoracic Surgery Clinics, vol. 21, no. 4, pp. 519525,
2011.
E. S. Hungness, E. N. Teitelbaum, B. F. Santos et al., Comparison of perioperative outcomes between peroral esophageal
myotomy (POEM) and laparoscopic Heller myotomy, Journal
of Gastrointestinal Surgery, vol. 17, no. 2, pp. 228235, 2013.
H. Inoue, H. Minami, Y. Kobayashi et al., Peroral endoscopic
myotomy (POEM) for esophageal achalasia, Endoscopy, vol. 42,
no. 4, pp. 265271, 2010.
D. Von Renteln, K. H. Fuchs, P. Fockens et al., Peroral endoscopic myotomy for the treatment of achalasia: an international
prospective multicenter study, Gastroenterology, vol. 145, no. 2,
pp. 309.e3311.e3, 2013.
M. B. Ujiki, A. K. Yetasook, M. Zapf, J. G. Linn, J. M. Carbray,
and W. Denham, Peroral endoscopic myotomy: a short-term
comparison with the standard laparoscopic approach, Surgery,
vol. 154, no. 4, pp. 893900, 2013.
L. L. Swanstrom, E. Rieder, and C. M. Dunst, A stepwise
approach and early clinical experience in peroral endoscopic
myotomy for the treatment of achalasia and esophageal motility
disorders, Journal of the American College of Surgeons, vol. 213,
no. 6, pp. 751756, 2011.
L. L. Swanstrom, A. Kurian, C. M. Dunst, A. Sharata, N.
Bhayani, and E. Rieder, Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure, Annals of
Surgery, vol. 256, no. 4, pp. 659667, 2012.
L. O. Jeansonne, B. C. White, K. E. Pilger et al., Ten-year followup of laparoscopic Heller myotomy for achalasia shows durability, Surgical Endoscopy, vol. 21, no. 9, pp. 14981502, 2007.
A. Csendes, I. Braghetto, P. Burdiles, O. Korn, P. Csendes, and A.
Henriquez, Very late results of esophagomyotomy for patients
with achalasia: clinical, endoscopic, histologic, manometric,
and acid reflux studies in 67 patients for a mean follow-up of 190
months, Annals of Surgery, vol. 243, no. 2, pp. 196203, 2006.

5
[32] R. Salvador, M. Costantini, G. Zaninotto et al., The preoperative manometric pattern predicts the outcome of surgical treatment for esophageal achalasia, Journal of Gastrointestinal
Surgery, vol. 14, no. 11, pp. 16351645, 2010.
[33] K. Zendehdel, O. Nyren, A. Edberg, and W. Ye, Risk of esophageal adenocarcinoma in achalasia patients, a retrospective
cohort study in Sweden, American Journal of Gastroenterology,
vol. 106, no. 1, pp. 5761, 2011.
[34] I. Leeuwenburgh, P. Scholten, J. Alderliesten et al., Long-term
esophageal cancer risk in patients with primary achalasia: a
prospective study, American Journal of Gastroenterology, vol.
105, no. 10, pp. 21442149, 2010.
[35] G. Zaninotto, C. Rizzetto, P. Zambon, S. Guzzinati, E. Finotti,
and M. Costantini, Long-term outcome and risk of oesophageal cancer after surgery for achalasia, British Journal of Surgery,
vol. 95, no. 12, pp. 14881494, 2008.
[36] V. F. Eckardt, T. Hoischen, and G. Bernhard, Life expectancy,
complications, and causes of death in patients with achalasia:
results of a 33-year follow-up investigation, European Journal
of Gastroenterology and Hepatology, vol. 20, no. 10, pp. 956960,
2008.
[37] J. R. Bessell, C. J. Lally, A. Schloithe, G. G. Jamieson, P. G. Devitt,
and D. I. Watson, Laparoscopic cardiomyotomy for achalasia:
long-term outcomes, ANZ Journal of Surgery, vol. 76, no. 7, pp.
558562, 2006.
[38] M. F. Loviscek, A. S. Wright, M. W. Hinojosa et al., Recurrent
dysphagia after Heller myotomy: is esophagectomy always the
answer? Journal of the American College of Surgeons, vol. 216,
no. 4, pp. 736743, 2013.
[39] R. P. Petersen and C. A. Pellegrini, Revisional surgery after
heller myotomy for esophageal achalasia, Surgical Laparoscopy,
Endoscopy and Percutaneous Techniques, vol. 20, no. 5, pp. 321
325, 2010.
[40] M. Onimaru, H. Inoue, H. Ikeda et al., Peroral endoscopic
myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical heller myotomy: a single
center prospective study, Journal of the American College of
Surgeons, vol. 217, no. 4, pp. 598605, 2013.
[41] D. Molena and S. C. Yang, Surgical management of end-stage
achalasia, Seminars in Thoracic and Cardiovascular Surgery, vol.
24, no. 1, pp. 1926, 2012.
[42] G. E. Boeckxstaens, G. Zaninotto, and J. E. Richter, Achalasia,
The Lancet, 2013.
[43] G. E. Boeckxstaens, V. Annese, S. B. Des Varannes et al., Pneumatic dilation versus laparoscopic hellers myotomy for idiopathic achalasia, The New England Journal of Medicine, vol. 364,
no. 19, pp. 18071816, 2011.
[44] M. G. Patti and C. A. Pellegrini, Esophageal achalasia 2011:
pneumatic dilatation or laparoscopic myotomy? Journal of
Gastrointestinal Surgery, vol. 16, no. 4, pp. 870873, 2012.
[45] M. Yaghoobi, S. Mayrand, M. Martel, I. Roshan-Afshar, R.
Bijarchi, and A. Barkun, Laparoscopic Hellers myotomy versus
pneumatic dilation in the treatment of idiopathic achalasia: a
meta-analysis of randomized, controlled trials, Gastrointestinal
Endoscopy, vol. 78, no. 3, pp. 468475, 2013.

Journal of

Obesity

Gastroenterology
Research and Practice
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2013

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

The Scientific
World Journal
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2013

Journal of

Diabetes Research
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2013

Endocrinology

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

BioMed Research
International

Hindawi Publishing Corporation

http://www.hindawi.com

ISRN
AIDS
Hindawi Publishing Corporation
http://www.hindawi.com

MEDIATORS
of

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

ISRN
Biomarkers
Volume 2013

Volume 2013

INFLAMMATION

Computational and
Mathematical Methods
in Medicine

Oxidative Medicine and

Cellular Longevity
Volume 2013

Volume 2013

Research

Volume 2013

Clinical &
Developmental
Immunology

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

PPAR

Submit your manuscripts at

http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Evidence-Based
Complementary and
Alternative Medicine

International Journal of

Hindawi Publishing Corporation

http://www.hindawi.com

Journal of

Oncology

Hindawi Publishing Corporation

http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

ISRN
Addiction
Volume 2013

Hindawi Publishing Corporation

http://www.hindawi.com

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013

ISRN
Anesthesiology
Volume 2013

Hindawi Publishing Corporation

http://www.hindawi.com

Journal of

Ophthalmology
Hindawi Publishing Corporation
http://www.hindawi.com

Volume 2013

ISRN
Allergy
Volume 2013

Hindawi Publishing Corporation

http://www.hindawi.com

Volume 2013