A patient has been diagnosed with achalasia. He refused surgery initially, preferring to try nonoperative therapy. He tried life-style modification, calcium channel blockers, botulin toxin injection, and endoscopic pneumatic dilatation. None of the treatments alleviated his symptoms. What are his surgical options?

A healthy patient with achalasia who has failed nonoperative management should be considered for surgical intervention. Pneumatic dilatation is first-line therapy. It causes disruption of the muscular layers of the LES. A balloon is placed endoscopically at the level of the LES. Fluoroscopically is used to visualize the balloon as it is inflated to pressures no higher than 10 psi. If pneumatic dilatation fails, or if symptoms return after successful dilation, surgery should be considered. The procedure may be done open or endoscopically. The operation involves a myotomy that divides the circular and longitudinal muscle fibers. It extends from the distal 6 cm of the esophagus, through the LES, and the proximal gastric cardia. A partial fundoplication is usually included to prevent gastroesophageal reflux.