The last three decades have witnessed a progressive evolution in the surgical treatment of esophageal achalasia, with a shift from open to a minimally invasive Heller myotomy. The laparoscopic approach is currently the standard of care with better short-term outcomes and similar long-term functional results when compared to open surgery. This shift in the treatment algorithm reflects the fact that laparoscopic Heller myotomy (LHM) with partial fundoplication outperforms nonsurgical approaches, such as balloon dilatation and intrasphincteric botulinum toxin injection. Lately the development of a totally endoscopic approach such as the peroral endoscopic myotomy “ P.O.E.M” opened new avenues in the treatment of this disease. The growth of P.O.E.M from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed, attests to the success and safety of this technique suggesting at least equivalence of P.O.E.M to LHM.

The last decade has witnessed also major improvements in diagnostic tools. High-resolution manometry (HRM) with 36 pressure transducers spanning the esophagus has revolutionized the diagnosis and treatment of esophageal motility disorders, especially with respect to achalasia. The main contribution of HRM for the diagnosis of achalasia is the characterization of three distinct subtypes of achalasia-type I (no distal pressurization), type II (panesophageal pressurization), and type III (spastic contractions). Subtypes predict the success of treatment with type II patients doing the best and type III being the most difficult to treat.

In this lecture, we describe our approach to achalasia discussing patients selection, preoperative evaluation, operative technique, and postoperative management.