During the 1970s and 1980s pneumatic balloon dilatation was considered the primary form of treatment for achalasia. During that period, very few myotomies were performed, mostly for patients whose dysphagia did not improve with balloon dilatation or whose esophagus was perforated during a balloon dilation [5]. In 1991 we performed the first thoracoscopic Heller myotomy [2]. We followed Ellis’ technique and extended the myotomy for 5 mm only onto the gastric wall [2]. The rationale for this approach was to make the myotomy long enough to relieve dysphagia but short enough to avoid reflux and therefore the need for a fundoplication. In a review of his 22-year experience with 197 patients Ellis documented symptomatic reflux in only 9 (5 %) of them [2]. However, his analysis was based on symptom evaluation only (presence of heartburn) rather than objective evaluation of the reflux status by pH monitoring. Symptoms may underestimate the reflux as most patients who develop reflux after a Heller myotomy do not experience heartburn [6, 7]. As a matter of fact, when Ellis used pH monitoring to objectively assess gastroesophageal reflux after the myotomy, he found abnormal esophageal acid exposure in 29 % of patients [8].

To avoid or limit the development of gastroesophageal reflux, surgeons in Europe [9] and South America [10] traditionally used a transabdominal approach, performing a longer myotomy onto the gastric wall in combination with an anti-reflux procedure. For Bonavina and colleagues excellent or good results in 94 % of patients while the rate of postoperative reflux measured by pH monitoring was 8.6 % only [9].

Shimi and Cuschieri first reported in 1991 the performance of a Heller myotomy for esophageal achalasia by minimally invasive techniques [11]. In 1992 we described our initial experience with a thoracoscopic Heller myotomy [12] using the technique developed by Cuschieri [11], and performed a left thoracoscopic myotomy (with the guidance of intraoperative endoscopy) which extended for only 5 mm onto the gastric wall. The long-term follow-up in the first 30 patients who underwent a left thoracoscopic Heller myotomy confirmed the excellent outcome of the initial report: almost 90 % of patients had relief of dysphagia, the hospital stay was short, the postoperative discomfort was minimal, and the recovery was fast. However, some shortcomings of the thoracoscopic technique soon became apparent, particularly when compared to the laparoscopic approach [13]. We found in that a thoracoscopic myotomy was associated to reflux in 60 % of patients studied postoperatively by pH monitoring. We also encountered patients who already had abnormal reflux secondary to dilatation even though they still experienced dysphagia. Some of these patients had very low LES pressure [14].

These were probably the key reasons that made us switch to a laparoscopic myotomy and Dor fundoplication as suggested by Ancona and colleagues [15]. in the attempt to find a balance between relieving dysphagia and avoiding postoperative reflux. Others followed our example [16, 17].

It is generally accepted that a fundoplication is necessary to prevent reflux after a laparoscopic Heller myotomy, by either performing a Dor fundoplication [18–24], a Toupet fundoplication [25–28], or a Nissen fundoplication [29–31].

This approach is based on some retrospective studies and two prospective randomized trials comparing laparoscopic myotomy alone versus myotomy and fundoplication. Kjellin and colleagues found abnormal reflux by pH monitoring in 8 of 14 (57 %) patients after laparoscopic myotomy without fundoplication [32]. Five of the 8 patients (62 %) were asymptomatic. Similarly, Burpee and colleagues documented reflux (by pH monitoring or endoscopy) in 18 of 30 patients (60 %) after laparoscopic Heller myotomy without fundoplication [33]. Thirty-nine per cent of patient with reflux were asymptomatic. Gupta and colleagues reported heartburn after laparoscopic myotomy in 80 % of their patients. They felt that it was not a problem as symptoms were well controlled with medications [34].

The observation of a very high incidence of reflux after laparoscopic myotomy alone has also been confirmed by two prospective and randomized trials. In 2003 Kalkenback and colleagues reported the results of a prospective randomized trial comparing myotomy alone versus myotomy and Nissen fundoplication [29]. Postoperative reflux was present in 25 % of patients who had a myotomy and fundoplication but in 100 % of patients who had a myotomy alone. Twenty-percent of the patients in the latter group developed Barrett’s esophagus.

In 2004 Richards and colleagues reported the results of a prospective randomized trial comparing laparoscopic myotomy alone versus laparoscopic myotomy and Dor fundoplication [24]. Postoperative ambulatory pH monitoring showed reflux in 48 % of patients after myotomy alone but in only 9 % of patients when a Dor fundoplication was added to the myotomy. The incidence and the score of postoperative dysphagia were similar in the two groups.

Based on these data we feel that a fundoplication should be performed after a laparoscopic Heller myotomy. It is dangerous to claim that postoperative reflux does not matter and that nothing should be done to prevent it. Today we are operating on many young patients [35] who may develop severe esophageal damage if exposed to years of reflux [1–4].

It has been shown that a laparoscopic total (360°) fundoplication is the procedure of choice in patients with gastroesophageal reflux disease. When compared to a partial fundoplication, a total fundoplication determines a better control of reflux without a higher incidence of postoperative dysphagia, even when esophageal peristalsis is weak [36]. In esophageal achalasia, however, there is no peristalsis. Therefore, a total fundoplication might determine too much of a resistance at the level of the gastroesophageal junction, impeding the emptying of food from the esophagus into the stomach by gravity, and eventually causing persistent or recurrent dysphagia. Albeit some groups still claim good results adding a total fundoplication after a myotomy [29–31], others have abandoned this approach and switched to a partial fundoplication. This decision was based on the results of long-term studies which showed that esophageal decompensation and recurrence of symptoms eventually occurs in most patients [37–41]. For instance, Duranceau and colleagues initially reported excellent results with a Heller myotomy and total fundoplication [39]. Ten years later, however, they noted that symptoms had recurred in 14 of 17 patients (82 %), five of whom required a second operation [40]. They felt that over time the total fundoplication determines a progressive increase in esophageal retention with poor emptying and recurrence of symptoms. They were able to correct this problem by switching to a partial fundoplication [41]. In 2008 Rebecchi and colleagues reported the results of a prospective and randomized trial comparing a Heller myotomy plus Nissen to a Heller myotomy plus Dor. At 10 year follow up the rate of recurrent dysphagia was 15 % after Nissen fundoplication, but only 2.8 % after Dor [42]

Today a laparoscopic Heller myotomy with partial fundoplication is considered the procedure of choice for esophageal achalasia, as it attains the best balance between relief of dysphagia and prevention of reflux [43].

Some groups feel that a posterior fundoplication is better choice as it keeps the edges of the myotomy separated and it is a more effective antireflux operation [25–28]. Others, however, feel that a Dor fundoplication is simpler to perform as it does not need posterior dissection, and it adds the advantage of covering the exposed mucosa [18–24]. A prospective, multicenter and randomized trial published in 2013 compared the results of a myotomy plus Dor with that a myotomy plus Toupet [44]. They found no difference of symptoms improvement and incidence of postoperative reflux.