Predicting success after laparoscopic heller myotomy: lessons from 22 years in a resource-limited context

Achalasia is a rare primary esophageal motility disorder. While laparoscopic Heller myotomy (LHM) is a well-established treatment worldwide, no studies to date have evaluated its long-term outcomes and risk factors for failure in low- and middle-income countries (LMICs). In our context, peroral endoscopic myotomy (POEM) remains uncommon, and surgery is still the first-line treatment. This study aims to evaluate the functional and symptomatic outcomes of laparoscopic Heller myotomy (LHM), identify risk factors associated with surgical failure, and highlight the benefits of concomitant anti-reflux procedures in reducing the incidence of gastroesophageal reflux.

We conducted a retrospective analysis of 55 consecutive patients who underwent LHM with or without an anti-reflux system (ARS) between July 2000 and December 2022. Clinical success was defined as the resolution of dysphagia with a concomitant improvement in the Eckardt score, corroborated by objective assessments including lower esophageal sphincter (LES) pressure measurements and 24-hour pH-metry. Iatrogenic reflux was diagnosed based on clinical symptoms and confirmed through esophageal pH-metric evaluation. Potential risk factors contributing to treatment failure were systematically analyzed.

Dysphagia (98.2%) and weight loss (74.5%) were the predominant symptoms. In our series, two conversions were reported (3.6%) following esophageal perforation. Nineteen patients (34.5%) had undergone ARS, with 10 of DOR type (18.2%) and 9 of Toupet/Nissen type (16.4%). With a mean follow-up of 24.47 months, dysphagia had disappeared in 51 (92.8%) and the mean Eckardt score was improved by 0.92 (+/- 1.25) vs. 5.46 (+/- 1.77) with P=<0.05. All patients with persistent dysphagia had lost weight preoperatively (P=0.05). The absence of an anti-reflux system was associated with more gastro-esophageal reflux disease (16.7% vs. 5.2%, P=0.181) and more esophageal exposure to gastric acid (9.1% vs. 16.4%, P=0.224). ARS, whether Dor or Toupet, were effective in preventing postoperative reflux.

In our LMIC setting, LHM remains the gold standard for achalasia treatment given the limited availability of POEM. When combined with ARS, it provides durable symptom control, prevents reflux, and maintains good functional results. Preoperative weight loss may predict poorer postoperative outcomes.