Oesophageal myotomy (or Heller myotomy) is a procedure that can be performed to treat a lower oesophageal sphincter that fails to relax (e.g. achalasia). The procedure involves a longitudinal incision of the distal oesophageal musculature to break the sphincter tone.
A fundoplication wrap can be performed to restore some patency to the lower oesophageal sphincter. A section of the gastric fundus is wrapped around the gastro-oesophageal 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 oesophagus 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 oesophageal myotomy (POEM), is increasing in use in some centres.
Radiographic features
Fluoroscopy
On contrast swallow examination, there may be characteristic "ballooning" of the distal oesophagus after a myotomy (50%), as the oesophagus 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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