Cardiomyotomy in achalasia: which fibers do we cut?

Until now, it has not been quite clear which muscular fibers are cut when a cardiomyotomy for achalasia is carried out. In the present report, in a hu man achalasic gastroesophageal specimen, the mucosa of the stenotic segment was stripped off, allowing the fibers of the inner muscular coat to be see n. In addition, three cardiomyotomies at different sites were simulated. In achalasic specimens, the stenotic area is formed by the semicircular ('cla sp') and oblique ('sling') muscular fibers. Different myotomies section the se two muscular bands in distinct proportions. The stenotic segment in acha lasia coincides topographically with the anatomic lower esophageal sphincte r area. The site of cardiomyotomy is not irrelevant because this sphincter is not an annular muscle and the two muscular components of the sphincter c an be sectioned in different ways. This may be important in post-operative results with regard to the relief of dysphagia and the appearance of gastro esophageal reflux.