Background
In 1913, Ernest Heller reported the first successful cardiomyotomy for achalasia.
He used 8-cm parallel myotomies (anterior and posterior). These were considered extensive, and in 1918, De Brune Groenveldt and Zaaijer described the single incision known today. This transabdominal approach remained the criterion standard in Europe until it was superseded by minimally invasive techniques.
In North America, however, the Heller myotomy approach of choice was via a left thoracotomy after being described in this way by Ellis et al in 1958. Traditionally, no associated antireflux procedure was performed. The transabdominal approach is now the most common way of performing an open Heller myotomy.
Pneumatic dilation, with its 2% risk of perforation, was historically the first choice for achalasia treatment, with surgery reserved for failures. Calcium-channel blockers and long-acting nitrates have been attempted as medical therapy to reduce lower esophageal sphincter (LES) tone but are relatively short-acting, do not improve LES relaxation in response to swallowing, have significant side effects (eg, headache), and have little overall success. Botulinum toxin injections can be temporarily successful, primarily in older patients.