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Page 2 of 3 Herbella et al. Mini-invasive Surg 2019;3:24 I http://dx.doi.org/10.20517/2574-1225.2019.20

considered secondary, and treatment is directed toward reflux. In the absence of GERD, therapy is aimed at
the modulation of the esophageal dysmotility with pharmacological agents or at the permeabilization of the
[4]
gastroesophageal junction with endoscopic or surgical procedures .
Surgical treatment for non-achalasia PEMD was reserved for few situations during the conventional
manometry era. Cardiomyotomy (Heller’s operation) and fundoplication are used for patients with
hypertensive lower esophageal sphincter, diffuse esophageal spasm or nutcracker esophagus and obstructive
[5,6]
symptoms . Proper selection of patients is linked to good outcomes with low morbidity, which makes
surgical therapy an adequate therapeutic option. Interestingly, literature is scarce on surgical therapy for
this new classification with per oral endoscopic myotomy (POEM) as the leading treatment.

Ineffective esophageal motility is not treated by surgery. Hypertensive lower esophageal sphincter is no
longer a PEMD according to Chicago 3.0.

There are no studies on Heller’s myotomy for distal esophageal spasm (previously diffuse spasm) based on
[7-9]
the new classification. Some case reports of POEM for distal spasm have been reported with multicenter
[10]
studies encompassing a larger number of patients but always inferior to 20 in total . Experience with
the method is too short to draw conclusions. The same is true for jackhammer esophagus: no studies on
Heller’s myotomy and few case reports for POEM [9,11] . A recent systematic review compiling these small
[12]
series showed a clinical success of 90%.

Esophagogastric junction outflow obstruction is an altered motility pattern contemplated by Chicago 3.0
classification. Most cases are associated to mechanical obstruction especially after operations in the area.
[13]
Few cases are considered PEMD . Interestingly, some cases treated by Heller’s myotomy [13-15] showed good
[16]
outcomes while POEM did not show good results .
In conclusion, Heller’s myotomy and fundoplication are currently underused for the treatment of non-
achalasia PEMD. POEM is the preferred treatment, but long-term results with larger series are still elusive.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Herbella FAM, Schlottmann F

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.