Heller myotomy in patients with prior endoscopic interventions vs the treatment-naïve

Definitive palliation for achalasia is surgical myotomy; however, patients frequently undergo endoscopic treatments prior to myotomy. Surgeons may perceive myotomy to be more challenging after prior treatments, due to scarring and fusion of dissection planes, but outcomes compared to the treatment-naïve remain unclear. Hence, we compared institutional Heller myotomy outcomes in patients who underwent pre-myotomy endoscopic treatments to those who did not.

From 1/1/2010 to 1/1/2020, 436 patients underwent Heller myotomy for achalasia at Cleveland Clinic, 101 (23%) of whom had prior endoscopic intervention(s): 39 (39%) pneumatic dilation, 57 (56%) botulinum toxin injection, and 5 (4.9%) both (Prior group). Propensity score matching generated two groups of 101 pairs. Short-term outcomes and longitudinal postoperative symptom palliation (Eckardt score ≤ 3), esophageal emptying at five minutes, and reintervention were assessed and compared with the treatment-naïve (Naïve group).

There were no statistically significant differences in operative time, mucosal perforation, or length of stay between Prior and Naïve groups (P > .12). At 5 years, the probability of symptom palliation was 83% in the Prior Group vs 81% in the Naïve Group (P = .63) and complete esophageal emptying 23% vs 32% (P = .095). The cumulative number of reinterventions per 100 patients at 10 years was 7.9 in the Prior Group and 4.8 in the Naïve Group (P = .13).

The perception of increased complexity of Heller myotomy in patients with prior endoscopic interventions does not translate to stastically significant differences in short- or long-term outcomes when compared to the treatment-naïve. A subtle longitudinal pattern of suboptimal esophageal emptying and increased reintervention for patients with prior intervention(s), suggests that, when possible, up-front myotomy may be preferred.