A myotomy is a surgical procedure in which a surgeon cuts into a muscle that isn’t relaxing properly, allowing food or liquid to pass through more easily. The term literally means “cutting into muscle.” It’s most commonly performed on the esophagus or stomach, where a ring of muscle has become too tight or too thick, creating a blockage. The specific muscle that’s cut, and the method used to reach it, depends on the condition being treated.
How a Myotomy Works
Certain muscles in your digestive tract act as gates, opening and closing to control the flow of food. When one of these muscles stops relaxing on cue, food gets stuck. Medications and other therapies can sometimes coax the muscle to loosen, but when those fail, a myotomy physically divides the muscle fibers so they can no longer squeeze shut.
During the procedure, a surgeon cuts through the outer muscular layer while leaving the inner lining (the mucosa) intact. Think of it like slicing through the tough outer skin of a sausage without piercing the casing underneath. Once the muscle fibers are divided, the passageway opens and food can move through normally again.
Conditions Treated With a Myotomy
The most common reason for an esophageal myotomy is achalasia, a condition where the lower esophageal sphincter (the muscular valve between your esophagus and stomach) fails to relax when you swallow. Food and liquid back up in the esophagus, causing difficulty swallowing, chest pain, and regurgitation. Achalasia comes in three subtypes based on how the esophagus behaves during a pressure test called manometry, and all three can be treated with a myotomy.
Beyond achalasia, myotomy is also used for other esophageal motility disorders. Diffuse esophageal spasm, where the esophagus contracts in uncoordinated bursts, and jackhammer esophagus, where contractions are abnormally powerful, both respond well to surgical myotomy when medications and less invasive treatments haven’t worked.
A different type of myotomy targets the upper esophageal sphincter. Called a cricopharyngeal myotomy, this procedure treats people who have trouble swallowing at the throat level, often due to a neurological condition or a pouch called a Zenker’s diverticulum that forms when the upper sphincter doesn’t open properly.
In infants, a pyloromyotomy treats pyloric stenosis, a condition where the muscle at the exit of the stomach becomes abnormally thick and blocks food from reaching the intestines. This affects roughly 4 to 5 out of every 1,000 newborns, with a strong tendency toward boys. The procedure, first described over 110 years ago, remains the standard treatment.
Types of Myotomy Procedures
Heller Myotomy
The Heller myotomy is the most well-known version and has been the gold standard for treating achalasia. It’s performed laparoscopically: a surgeon makes five small incisions in the abdomen, inserts a tiny camera and surgical tools, then makes a lengthwise cut through the muscular layer of the lower esophagus and the top of the stomach. This opens the lower esophageal sphincter permanently.
Because cutting the sphincter open can allow stomach acid to flow back into the esophagus, surgeons often add a second step called fundoplication, in which part of the stomach is wrapped around the lower esophagus to create a new anti-reflux barrier. A comparative analysis published in the American College of Gastroenterology’s journal found that patients who had a Heller myotomy without fundoplication were roughly twice as likely to develop acid reflux afterward. For every 10 patients who skip the fundoplication, one will develop reflux that wouldn’t have occurred with it.
Peroral Endoscopic Myotomy (POEM)
POEM is a newer approach that avoids any external incisions. Instead, a surgeon passes a flexible endoscope through your mouth and into the esophagus, creates a tunnel within the esophageal wall, and then cuts the inner circular muscle fibers from the inside. The entry point is sealed with clips when the procedure is finished.
One of POEM’s biggest advantages is flexibility. Unlike a Heller myotomy, which can only reach the lower portion of the esophagus, POEM allows the surgeon to access the full length of the esophageal body. This makes it particularly useful for conditions like diffuse esophageal spasm or type III achalasia, where the problematic muscle spasms occur higher up. POEM is also an option for patients who had a previous Heller myotomy that didn’t fully resolve their symptoms, or who failed botulinum toxin injections or balloon dilation.
POEM isn’t suitable for everyone. Patients who’ve had prior radiation therapy to the esophagus or extensive removal of esophageal tissue in the treatment area are generally not candidates.
How Doctors Decide You Need One
The key diagnostic test is esophageal manometry, which measures the pressure and coordination of muscle contractions along the esophagus. A thin, flexible tube is passed through the nose into the esophagus, and you’re asked to swallow while the tube records pressure readings.
For achalasia, the hallmark finding is a lower esophageal sphincter that doesn’t relax properly, measured by something called the integrated relaxation pressure. When that pressure is above normal (roughly above 15 mmHg, depending on the equipment used) and the esophagus shows no normal peristalsis, the diagnosis is confirmed. The three subtypes are then distinguished by the pattern of contractions: type I shows no pressure waves at all, type II shows simultaneous pressurization across the esophagus in at least 20% of swallows, and type III shows rapid, spastic contractions.
Surgery doesn’t have to be the first step for every patient. Doctors typically try less invasive treatments first, including medications that relax smooth muscle, botulinum toxin injections into the sphincter, or balloon dilation to stretch it open. When those approaches fail, or for patients with achalasia subtypes that respond better to surgery, myotomy becomes the recommended treatment.
What Recovery Looks Like
For a minimally invasive Heller myotomy, you can expect to stay in the hospital for about two to three days. Most people are able to take clear liquids the same day as surgery. Soft foods typically come in two to three days later, and within about a month, most patients return to a normal diet. POEM recovery tends to follow a similar timeline, sometimes slightly shorter since there are no abdominal incisions to heal.
The transition back to solid food is gradual and deliberate. Your surgical team will give you specific guidance, but the general pattern moves from clear liquids to full liquids, then soft foods, and finally regular meals. Eating slowly, chewing thoroughly, and taking smaller bites becomes a lasting habit for many patients even after full recovery.
Long-Term Effectiveness
Myotomy has strong long-term results. In a study tracking patients after laparoscopic Heller myotomy over an average of 6.4 years, 80% remained free from treatment failure. At final follow-up, 96% reported significant symptom improvement compared to before surgery. That means the vast majority of patients experience lasting relief, though a small percentage may need additional treatment down the line, such as dilation or a POEM procedure.
The most common long-term issue is acid reflux, which is why the addition of a fundoplication during a Heller myotomy matters. Patients who do develop reflux after myotomy can usually manage it with standard acid-reducing medications. In rare cases, the myotomy may not cut deeply enough or scar tissue can partially close the opening over time, requiring a repeat procedure.