A Heller myotomy is a surgical procedure that cuts through the muscle fibers at the bottom of the esophagus to allow food and liquid to pass into the stomach. It is the primary surgical treatment for achalasia, a condition where the valve between the esophagus and stomach fails to relax properly during swallowing. The procedure has a long track record, with success rates above 90% in the first several years and durable relief lasting a decade or more for most patients.
Why the Procedure Is Needed
In a healthy esophagus, the lower esophageal sphincter opens automatically when you swallow, letting food drop into the stomach. In achalasia, that sphincter stays clenched. Food and liquid back up in the esophagus, causing progressive difficulty swallowing both solids and liquids, regurgitation of undigested food, chest pain, nighttime coughing, and sometimes significant weight loss.
Achalasia is diagnosed with a test called high-resolution manometry, which measures pressure patterns inside the esophagus. The condition comes in three subtypes. Type II is the most common (50% to 70% of cases) and responds best to treatment. Type I accounts for 20% to 40% of cases. Type III is rare, making up about 5% of cases, and tends to have the worst outcomes regardless of treatment approach. Current guidelines from the American College of Gastroenterology recommend a Heller myotomy as a primary treatment option for types I and II, and as a tailored option for type III.
What the Surgeon Actually Does
The operation is straightforward in concept. The surgeon cuts through all the circular and longitudinal muscle fibers surrounding the lower esophagus and the top of the stomach. The incision extends 4 to 6 centimeters up the esophagus and 1.5 to 3 centimeters down onto the stomach. This eliminates the squeeze that was blocking food from passing through.
Cutting through the muscle solves the swallowing problem but creates a new vulnerability: without that muscular barrier, stomach acid can wash back up into the esophagus. Performing a myotomy alone has been shown to increase acid reflux significantly, so surgeons almost always add an antireflux procedure called a fundoplication. This involves wrapping a portion of the upper stomach around the base of the esophagus to create a new valve-like barrier.
Two types of fundoplication are commonly paired with the myotomy. A Dor fundoplication wraps the stomach over the front of the exposed esophagus, covering the area where muscle was cut and requiring less surgical dissection. A Toupet fundoplication wraps the stomach around the back, which some surgeons prefer because the wrap helps keep the cut muscle edges separated and may reduce reflux slightly more. Both provide effective reflux protection, and the choice often comes down to surgeon preference and the specifics of each case.
Laparoscopic, Robotic, and Open Approaches
Today, nearly all Heller myotomies are performed using a minimally invasive approach, either laparoscopic (using small incisions and a camera) or robotic-assisted. Open surgery through a larger incision is rarely necessary. The laparoscopic approach is considered the standard, with an overall success rate of about 92%.
Robotic-assisted surgery is gaining ground. A comparison of robotic versus laparoscopic Heller myotomy found that the robotic approach had zero intraoperative perforations compared to a 13.6% perforation rate with traditional laparoscopy. Patients in the robotic group also went home sooner, with a median hospital stay of one day versus two. The added precision of robotic instruments appears to reduce the risk of accidentally cutting through the inner lining of the esophagus, which is the most technically demanding aspect of the procedure.
How It Compares to POEM
Peroral endoscopic myotomy, or POEM, is a newer alternative that accomplishes a similar muscle-cutting goal but through a flexible scope passed down the throat, leaving no external incisions. POEM generally takes less time in the operating room, causes less postoperative pain, and has a lower overall rate of adverse events. One multicenter study found a complication rate of 6% for POEM versus 27% for a Heller myotomy. For short-term relief of swallowing difficulty, POEM appears to have a slight edge.
The tradeoff is reflux. Because POEM does not include a fundoplication, postoperative acid reflux rates range from 19% to 50%, compared to much lower rates when a Heller myotomy is paired with a stomach wrap. Reflux esophagitis, where acid damages the esophageal lining, has been reported in roughly 40% of POEM patients in some case series. For patients concerned about long-term reflux or who already have reflux symptoms, a Heller myotomy with fundoplication may be the better choice. Current guidelines consider both procedures appropriate first-line options for type I and type II achalasia, with the decision depending on the patient’s subtype, preferences, and the expertise available at their treatment center.
Risks and Complications
Esophageal perforation is the most significant risk during surgery, occurring in up to 7% of laparoscopic cases. This happens when the surgeon’s cut goes too deep and punctures the inner lining of the esophagus. When caught during the procedure, it can usually be repaired immediately. In rare cases, a perforation discovered afterward may require treatment with an endoscopic stent.
Postoperative acid reflux is the most common long-term concern, which is why the fundoplication step is so important. A small percentage of patients experience recurrent swallowing difficulty over time as scar tissue forms or the myotomy proves insufficient. Some patients eventually need a repeat procedure or a different intervention years later.
Long-Term Results
In the first five years after surgery, reported success rates range from about 50% to 98%, with most studies clustering toward the higher end. The wide range reflects differences in how “success” is defined and variations in surgical technique. Studies tracking patients beyond 10 years show that roughly 79% to 91% continue to report meaningful symptom relief. One study following patients for a median of 17 years found that 79% still had good symptom control. These numbers mean that while most people get lasting benefit, a meaningful minority will need additional treatment eventually.
Recovery and Diet Progression
Most patients spend one to two nights in the hospital after a laparoscopic or robotic Heller myotomy. The recovery diet follows a careful progression to let the surgical site heal without being stressed by solid food.
For the first one to two days, you’ll be limited to clear liquids: water, broth, juice, gelatin, and decaffeinated tea. Carbonated beverages should be avoided. From roughly day two through day seven, you can move to full liquids like milk, strained cream soups, plain yogurt, ice cream, and nutritional supplements. Starting around one week after surgery, soft foods are introduced: scrambled eggs, oatmeal, mashed potatoes, fish, soft rice, pasta, and steamed vegetables. You’ll typically return to a normal diet after your two-week follow-up appointment, though your surgeon may adjust this timeline based on how you’re healing.
Most people return to normal daily activities within two to three weeks, though heavy lifting and strenuous exercise may be restricted for longer. The swallowing improvement is often noticeable almost immediately, even while on the liquid diet, which for many patients is the first time in months or years that anything has gone down easily.