Related Experiment Video
Updated: Aug 7, 2026
Robotic Myotomy and Partial Fundoplication for Achalasia
Published on: August 11, 2023
Heller myotomy vs Heller myotomy plus Dor fundoplication: cost-utility analysis of a randomized trial
A Torquati1, R Lutfi, L Khaitan
1Department of Surgery, Vanderbilt University Medical School, Nashville, TN 37232, USA. alfonso.torquati@vanderbilt.edu
Insights
Adding Dor fundoplication to Heller myotomy for achalasia significantly reduces GERD risk and is more cost-effective long-term. This combined approach offers better outcomes and value compared to Heller myotomy alone.
Area of Science:
- Gastroenterology
- Surgical Oncology
- Health Economics
Background:
- Laparoscopic Heller myotomy for achalasia can lead to gastroesophageal reflux (GER).
- Dor antireflux procedures reduce GER risk post-myotomy, but cost-effectiveness is unclear.
- This study evaluates the economic and clinical benefits of adding Dor fundoplication to Heller myotomy.
Purpose of the Study:
- To estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication versus Heller myotomy alone for achalasia patients.
- To compare the long-term outcomes and costs of the two surgical strategies.
Main Methods:
- A cost-utility analysis using a Markov simulation model was performed.
- The model simulated a 10-year time horizon for expected costs and quality-adjusted life expectancy.
- Data were derived from a randomized clinical trial, with comparisons using incremental cost-effectiveness analysis.
Main Results:
- Heller plus Dor significantly reduced pathologic GER incidence (9.1% vs. 47.6%) and GERD risk (RR 0.11, p=0.01).
- The Heller plus Dor procedure incurred higher initial surgical costs ($942 more, 40 min longer OR time).
- Over 10 years, Heller plus Dor cost $6,861/patient with 9.9 QALYs vs. Heller alone at $9,541/patient with 9.5 QALYs.
Conclusions:
- Heller myotomy with Dor fundoplication is more effective in preventing postoperative GERD than Heller myotomy alone.
- The combined procedure is more cost-effective over a 10-year period, offering better value for achalasia patients.
Background:
The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia.
Methods:
We conducted a cost-utility analysis using the Markov simulation model to examine the two treatment alternatives. The model estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis.
Results:
The incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence interval 0.02-0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference $942; p = 0.04), secondary to a longer operating room time (mean difference 40 min; p = 0.01). At a time horizon of 10 years, when proton pump inhibitor (PPI) therapy costs are considered, the cost-utility analysis demonstrates that Heller plus Dor surgery is associated with a total cost of $6,861 per patient and a quality-adjusted life expectancy of 9.9 years, whereas Heller-alone surgery is associated with a cost of $9,541 per patient and a quality-adjusted life expectancy of 9.5 years.
Conclusions:
In achalasia patients, Heller myotomy plus Dor fundoplication is preferred to Heller alone because it is both more effective in preventing postoperative GERD and more cost-effective at a time horizon of 10 years.
