Some surgeons recommend an esophagectomy as primary treatment for achalasia when the esophagus is dilated, on the assumption that a myotomy cannot improve esophageal emptying and relieve dysphagia. However, even in very experienced hands, this operation has a very high morbidity and mortality. Devaney and colleagues reported on 93 patients with achalasia who underwent esophagectomy [4]. Indications for the operation were a tortuous mega-esophagus in 64 % of patients, failure of a prior myotomy (63 %) or peptic stricture (7 %). The stomach was used as the esophageal substitute in 91 % of cases. The average blood loss was 672 ml, and the average hospital stay was 12.5 days. The morbidity was quite high, with many patients having an anastomotic leak (10 %), hoarseness (5 %), chylothorax (2 %), bleeding necessitating a thoracotomy (2 %), and a tracheal tear (1 %). In addition, 42 % of patients experienced severe regurgitation postoperatively, and 46 % developed an anastomotic stricture requiring dilatations. Two patients died. A 4.2 % mortality was also reported by Pinotti and colleagues among 122 patients operated on for Chagas disease [7].

Others surgeons feel that a Heller myotomy should always be attempted regardless of the esophageal diameter. Sweet and colleagues evaluated the results of a laparoscopic Heller myotomy and Dor fundoplication in 113 patients with achalasia and various degrees of esophageal dilatation: group A 46 patients, diameter <4.0 cm (Fig. 15.2); group B 32 patients, diameter 4.0–6.0 cm (Fig. 15.3); group C 23 patients, diameter >6 cm and straight axis (Fig. 15.4); and group D 12 patients, diameter >6.0 cm and sigmoid shape esophagus (Fig. 15.5) [8]. The postoperative course was similar in the four groups. The degree of esophageal dilatation did not influence the outcome, as excellent or good results were obtained in 89 % of group A and 91 % of groups B, C, and D patients. None required esophagectomy to maintain clinically adequate swallowing [8].

Mineo and Pompeo performed a myotomy and an anterior fundoplication in 14 patients with achalasia and a dilated and sigmoid esophagus with excellent/good results in 10 patients and satisfactory results in 2. No patient required esophagectomy [9]. Similar results have been obtained by others in patients with idiopathic achalasia [10–12]. Pantanali and others, used this approach in 11 patients with Chagas disease and a massively dilated esophagus (diameter >10 cm) [13]. At a 31.5 month follow up, 5 patients (45 %) were asymptomatic, 4 patients (36 %) had mild and intermittent dysphagia, and two patients had no improvement. One of these patients eventually required an esophagectomy. Finally, Loviscek and colleagues evaluated a group of patients who had recurrent dysphagia after Heller myotomy and were treated by a second myotomy [14]. At a median follow-up of 63 months 19 of 24 patients had good result, and only 4 required an esophagectomy. A second myotomy performed laparoscopically is particularly effective in patients with a prior failed left transthoracic or thoracoscopic myotomy as the abdominal cavity and the right side of the esophagus are usually free of adhesions [15].

In Chap. 10 we have described the technical steps of the operation in patients with normal anatomy. When the esophagus is dilated and sigmoid some of the steps of the operation are quite different: