Overview
When the esophagus stops doing its job.
Achalasia is a swallowing disorder in which the muscle of the lower esophageal sphincter fails to relax, and the muscle of the esophageal body loses its normal squeezing pattern. Food and liquid pool in the esophagus instead of moving smoothly into the stomach. Patients describe swallowing as a slow, deliberate effort — and over time, weight loss, regurgitation, and night-time coughing follow. Untreated, achalasia gets progressively worse.
The mainstay of long-term treatment is a Heller myotomy — surgically dividing the muscle of the lower esophageal sphincter to relieve the obstruction. We pair the myotomy with a partial fundoplication (usually a Dor or Toupet wrap) to prevent the reflux that would otherwise occur once the sphincter is opened. Endoscopic alternatives — pneumatic dilation and POEM (per-oral endoscopic myotomy) — are options for selected patients, and we discuss all three openly in the office.
Who is a candidate?
Most patients with confirmed achalasia are candidates for surgery. Diagnosis requires esophageal manometry; we usually also obtain an upper endoscopy and a barium swallow. Pneumatic dilation is offered first to a subset of patients, but its effect is often temporary. Botox injection is reserved for patients who are not surgical candidates. Heller myotomy provides the most durable relief — symptom improvement in 85–90% of patients at 10 years.
How we perform it
Under general anesthesia, the operation is performed robotically through five small upper-abdominal incisions. The muscle layer of the lower esophagus is identified and divided from a few centimeters above the gastroesophageal junction to about 2 cm onto the stomach, while the inner mucosal lining is left intact. A partial fundoplication (anterior Dor or posterior Toupet wrap) is then performed to recreate an anti-reflux barrier and protect the now-open sphincter. The operation takes about 90 minutes.
Recovery
Most patients stay one night. The next morning we obtain a barium swallow to confirm no mucosal leak, then start clear liquids and progress through a soft diet over the next four weeks. Patients are off work for about a week and back to normal activity within two to three weeks. Swallowing improves quickly — often within days — and many patients eat solid food for the first time in months in the first few weeks after surgery.
Why Florida Surgical
Heller myotomy with partial fundoplication is the standard surgical treatment for achalasia, and it works very well when performed by a foregut-trained team using appropriate preoperative testing. Dr. Decio is fellowship-trained in foregut surgery and offers this operation routinely. We coordinate with gastroenterology for the diagnostic workup and for any follow-up endoscopic surveillance.
Frequently asked questions
What's the difference between Heller myotomy and POEM?
Both divide the lower esophageal sphincter muscle. Heller is done through the abdomen and includes a fundoplication. POEM is done through the mouth without external incisions, but it is associated with a higher rate of post-procedure reflux because no fundoplication is performed. Both are reasonable; the choice depends on patient anatomy, symptoms, and prior treatments.
Will my swallowing be normal again?
Most patients describe swallowing as dramatically improved. A few patients have mild residual dysphagia, often improved by small dietary changes. Long-term symptom relief is around 85–90% at 10 years.
Will I get reflux after the myotomy?
Without a fundoplication, yes — that's why we always perform a partial wrap. With the wrap, the rate of significant post-operative reflux is low (5–10%) and usually controllable with medication.
Can achalasia come back?
Achalasia itself does not recur, but the symptoms can return over years if the myotomy was incomplete or scar tissue forms. Most patients do well long-term; a small number need a repeat procedure or pneumatic dilation.
Should I try pneumatic dilation first?
It's reasonable, especially for older patients or those preferring a non-surgical approach. The trade-off is durability — dilation often needs to be repeated, while a well-done myotomy lasts.