Laparoscopic surgery for achalasia and other primary esophageal motility disorders (PEMD)-indications, preoperative investigations and patient's selection

Primary esophageal motility disorders (PEMD) including achalasia cardia are relatively rare disorders and diagnosed with relative accuracy using high-resolution manometry applying the new Chicago Classification v3.0. The role of additional investigations such endoscopy and barium swallow play a vital role in the diagnosis of achalasia, however their inclusion in diagnosing other PEMD is of no value as the esophagus is anatomically normal. Surgical treatment in the form of Heller myotomy and partial fundoplication is considered the gold standard for achalasia but there is uncertainty regarding the surgical treatment of other PEMD even when the patient experiences obstructive symptoms of dysphagia due to unpredictable outcome. It is therefore imperative that the patient selection and preoperative counseling should take the lead role in these patients before embarking on the surgical treatment. In recent days Heller myotomy has been challenged by a newer endoscopic technique of peroral endoscopic myotomy for achalasia treatment. However, the long-term results are still not available and caution is required. This review scrutinizes both the new and old literature regarding the diagnostic features, preoperative investigations, indications and patient's selection for the laparoscopic treatment of achalasia and other PEMD. It also aims to provide argument for and against various aspects of Heller myotomy in combination with antireflux procedures. It is hoped that further refinement of Chicago Classification may subgroup some of these PEMD and therefore provide clarity regarding the ones requiring definite surgical treatment for the improvement of their symptoms in long term.