[Myotomy of the esophageal body]

Extramucosal myotomy involving the external longitudinal and internal circular layers of the musculature of the esophagus represent the surgical therapy in patients with dysphagia and regurgitation or with angina-like chest pain secondary to functional abnormalities of the musculature of the esophagel body and sphincters. Surgery has a palliative function, because cures symptoms and complication such a diverticula, but not the disease. Modern surgical techniques also prevent recurrence of symptoms and complications are minimal with better long-term results than conservative therapy. Myotomy of the lower esophageal sphincter extended to the distal part of the esophageal body (Heller's operation) is performed as first choice or following insucces of dilatation in patients with primary achalasia of the esophagus, using a trans-abdominal or a trans-thoracic approach. Myotomy of the upper esophageal sphincter is indicated in patients with Zenker's diverticulum following diverticulectomy or diverticulopessy. Segmental myotomies are performed after diverticulectomy in patients with epiphrenic pulsion diverticula. Trans-thoracic "long" esophageal myotomy performed from the thoracic portion of the lower esophageal sphincter to the aortic arch is indicated in patients with diffuse esophageal spasm and nutcracker esophagus and sometimes in patients with aspecific abnormalities of the esophageal motor function associated with diverticula. Circular miotomies limited to the external longitudinal layer of the esophageal musculature can be performed at the level of anastomosis in order to gain tissue and reduce tissutal tension. The recent introduction of the endoscopic surgery allowed some of these operations to be performed through minimally invasive approaches. Therefore laparoscopic and thoracoscopic Heller's myotomy is feasible with clinical and functional results similar to those obtained with traditional open approach and with less postoperative discomfort and shorter hospital stay. This paper deals with the indications and surgical techniques of myotomies of the esophageal body both limited and extended to the lower esophageal sphincter.