Esophageal Myotomy with Antireflux Procedure: The surgical therapeutic maneuver to relieve  symptoms secondary to achalasia is an anterior esophageal myotomy (Heller myotomy). It will relieve the patient of their symptoms in 85 to 90% of the cases. Because of a high incidence of postoperative, symptomatic, severe gastro-esophageal reflux many authors have now combined this procedure with an anti-reflux procedure (Dor, Toupet or modified Nissen). As these patients have associated primary motility disorder which rarely improves after the myotomy, the associated antireflux procedure should be a Low Resistance Laparoscopic antireflux procedure (anterior or Toupet 270 deg. Fundoplication)

LES Injection of Botulinum Toxin: The introduction of Endoscopic LES Injection of Botulinum Toxin has changed the initial surgical management of these patients. Once a patient is diagnosed with achalasia, we initially refer him to our invasive gastroenterologist who will inject the LES with Botulinum Toxin. These patients usually do well for an average of one year to 18 months at which time they can  be routed toward a laparoscopic esophageal myotomy. It is our experience these patients do not benefit from multiple injections. In addition, most of our patients developed severe, post injection gastroesophageal reflux requiring medical management with Proton Pump Inhibitors. We are now changing this approach. During the patient's first office visit, they are given the choice of surgical versus medical management.

Hydrostatic Esophageal Dilatation: The hydrostatic dilatation of the lower esophagus still has a place in the management of these patients. This option is reserved for patients who are high surgical risks or patients with other life altering medical problems.