Achalasia is considered a chronic disease and cannot be cured, as the pathophysiology of the neural degeneration remains largely unclear. Therapeutic options are therefore directed toward symptom relief by lowering the LES pres­sure to improve transit of food into the stomach.

Complication rate is comparable to surgical Heller myotomy, and POEM carries a mortality risk approaching zero [2]. POEM seems to have promising advantages for treatment of achalasia, being less invasive in nature than the conventional extraluminal surgical approach, avoid­ing abdominal incisions, offering rapid recovery and the possibility to adapt the length of the desired myotomy. Since the first human study of POEM in 2010, numerous published studies, including thousands of patients world­wide, all report therapeutic success in 82–100% of patients with the longest follow-up in literature now at 5 years [3]. Prospective randomized studies comparing POEM with either LHM or PD are recently completed and results have been published in abstracts showing a higher 1-year thera­peutic success rate for POEM (clinical remission 92%) compared to PD (clinical remission 70%) (p < 0.01) and comparable results for POEM compared to LHM, with clin­ical success at 2 years achieved in 81.9% with POEM and in 80.4% with LHM [4, 5].

with the patient in supine position. The use of carbon dioxide gas for insufflation is essential since CO2 is more rapidly absorbed compared to air, reducing the risk of pneu­mothorax or tension pneumoperitoneum. However, abdomi­nal compartment syndrome can occasionally still occur with excessive CO2 insufflation. Abdominal decompression with an IV catheter needle inserted in the left upper quadrant after desufflation of the stomach can be a simple and effec­tive solution.

Heller myotomy has been the gold standard surgical tech­nique for treatment of esophageal achalasia, competing with other less aggressive options as dilation or Botox injection. The description of the laparoscopic approach by Cuschieri in 1991 [1] has converted surgery as the preferred treatment option in fit patients. Peroral endo­scopic myotomy (POEM), first performed by Inoue in 2008 [2], has promoted this approach as alternative for laparoscopic Heller myotomy after demonstrating the safety, reproducibility and efficacy in many centers around the world [2]. Meta-analysis and comparative trials have showed a similar efficacy, less invasiveness but increased gastroesophageal reflux [3–6]. POEM has a controver­sial weak technical point due to the impossibility to cre­ate an efficacious antireflux associated technique, and the incidence of post-procedural esophagitis is significantly higher than after Heller myotomy plus an antireflux pro­cedure. Laparoscopic Heller myotomy, in spite of the big success of POEM, continue to have an important thera­peutic role, especially in young people with a long life expectancy, as well in last stage with dilated esophagus, as well in reoperation in patients that may not be approached trough POEM [7].

Patients do not need any special preoperative preparation, except a liquid meal during the previous 48 hours in the case of a dilated esophagus and food retention. The anes­thesiologist should be aware of the risk of aspiration during induction of the anesthesia.

2. Surgery begins opening the hepatogastric membrane, preserving the liver nervous vagal branches (Fig. 9.1). The assistant hold and put traction on the upper gas­tric area, below the esophagogastric junction. The peritoneum covering the anterior face of the abdomi­nal esophagus is opened, and the anterior face of the esophagus is dissected, entering in the inferior mediasti­num (Fig. 9.2a, b). It is not necessary a wide dissection to avoid the circular dissection of the esophagus, main­taining the structure of the phreno-esophageal posterior fixation.

is created above the esophagogastric junction (EGJ) through the longitudinal esophageal muscle till the sub­mucosa space (Fig. 9.4). The access to this space, that usually is very easily dissected, permits to identify a safe submucosal plane. Myotomy may be undertaken in different ways. A practical and safe mode is to distract the muscular fiber of the longitudinal muscle, taking apart both lips of the muscular breach with two grasp­ers (Fig. 9.5a, b). Using gentle maneuvers is possible to expose the surface of the submucosa. The dissection is prolonged cranially advancing through the submucosa space, and the circular esophageal muscle wall is sec­tioned with cold scissors when needed (Fig. 9.6a, b).

5. The next step of the myotomy is to go down in direc­tion of the gastric wall. The transition between esopha­gus and gastric muscle wall is easily observed because

and bleeds more (Fig. 9.7). Other technical options for the myotomy are to use the electrocautery with a hook tip or the harmonic scalpel. The most severe risk is at this moment the mucosal perforation. Factors that favor perforation would be inadequate traction and presenta­tion of the esophagus wall, with a floppy tissue that may be damaged, or previous therapeutic manipulation of the GEJ as Botox injections or dilation that will cause fibrosis at the submucosa level. Is important to assure a section of the esophageal muscles wall in a segment of 5–7 cm cranially and 2–3 cm caudally. The caudal pro­gression reduces dysphagia but induces more severe reflux.

6. Once the surgeon considers that the myotomy is com­pleted, it should be checked with an intraoperative gastroscopy (Fig. 9.8). A flexible endoscopy is intro- duced and carefully approached to the lower esophagus.

A visual marker that the myotomy has been completed is that the insufflation of gas permits to see the gastric folds. The scope is introduced in the stomach assuring that the myotomy is complete and no transverse fibers remain at the myotomy site. This maneuver permit to rule out also the existence of a perforation, if it occurs is easily identified observing the mucosa herniation. If perforation is present it should be closed by a running suture of 4.0 absorbable material.