Journal of Gastrointestinal Surgery

, Volume 11, Issue 3, pp 309–313 | Cite as

Relief of Dysphagia after Laparoscopic Heller Myotomy Improves Long-Term Quality of Life

  • Yassar Youssef
  • William O. Richards
  • Kenneth Sharp
  • Michael Holzman
  • Nikilesh Sekhar
  • Joan Kaiser
  • Alfonso Torquati


Background and Objective

Quality of life (QoL) is getting more attention in the medical literature. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting. The aim of the study was to assess the impact of residual dysphagia on QoL after laparoscopic Heller myotomy for achalasia.


QoL was evaluated using the short-form-36 (SF-36) and postoperative dysphagia was assessed using a dysphagia score. The score (range 0–10) was calculated by combining the frequency of dysphagia (0=never, 1 = < 1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). Patients were classified in the Nonresponder group when their dysphagia score was in the upper quartile.


Questionnaires were mailed to 110 patients. The overall response rate was 91% with 100 patients (54 female) returning the questionnaires. The average follow-up was 3.3 years. There was a significative inverse correlation between dysphagia score and mental component (P = 0.0001) and total SF-36 (P = 0.001) scores. According to their postoperative dysphagia scores, 77 patients were assigned to the Responder Group and 23 patients to the Nonresponder Group. The two groups were similar in terms of age, gender, rate of fundoplication, and length of follow-up. Mental component and total SF-36 scores were significantly (P < 0.05) higher in the Responder group. Successful relief of dysphagia after Heller myotomy was associated with health-related quality of life scores that were 13 higher in Vitality (P < 0.05), 11 points higher in mental health (P < 0.05), and 12 points higher in General Health (P < 0.05). Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery.


Laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms, namely dysphagia, and this was projected on a significant improvement in quality of life and patient satisfaction.


Achalasia Quality of life Laparoscopic Heller myotomy Dysphagia SF-36 


Achalasia is a primary motility disorder of the esophagus characterized by loss of peristaltic waveform in the body and failure of the lower sphincter to relax in response to swallowing. The condition is relatively rare, occurring at an incidence of 0.5 to 1.0 in 100,000 of the general population1, and affects any age group2. The etiology of achalasia remains unknown, although in South America many patients have infestation by Trypanosoma cruzi as an underlying pathogenesis. The main symptoms are dysphagia and chest pain, although in the late stages regurgitation of swallowed material may occur. Other common symptoms include heartburn and weight loss.

At present time no treatment can reverse the degeneration of the myenteric plexus and restore normal relaxation of the lower esophageal sphincter (LES) with swallowing3. Therefore, the current treatment strategy is aimed to relief the main symptom of achalasia: the dysphagia. Subjective relief of dysphagia and body weight regain have been the most common endpoints used in studies aimed to evaluate the therapeutic outcome of Heller myotomy or endoscopic dilation. However, Quality of life (QoL) is getting more attention in the medical literature4. Treatment outcomes are now gauged by their effect on the QoL along with their direct effect on the diseases they are targeting.

We hypothesize that successful relief of achalasia symptoms after laparoscopic Heller myotomy is associated with improved QoL. To test this hypothesis, we assessed how residual dysphagia after laparoscopic Heller myotomy for achalasia affects long-term QoL.

Patients and Methods

Patients who underwent laparoscopic Heller myotomy for achalasia were mailed a follow-up survey under an IRB approved protocol. The survey included: a Short Form-36 (SF-36) health status questionnaire, a follow-up structured dysphagia score questionnaire5, and a query regarding long-term satisfaction. All patients who did not return the questionnaires received a second mailing or were allowed to answer the survey over the phone.

The SF-36 questionnaire includes 36 questions that yield an eight-scale profile of scores. Scores range from 0–100, with higher scores indicating better QOL. Scoring is designed so that the average American individual would score on average 50 with 10 points standard deviation. The eight scales of the questionnaire include: 1) general health, 2) physical functioning, 3) bodily pain, and 4) role-physical, which all correlate with the physical health summary measure; and 5) mental health, 6) social functioning, 7) vitality, and 8) role-emotional, all of which correlate with the mental health summary measure.

The dysphagia score (range 0–10) was calculated by combining the frequency of dysphagia (0=never, 1 = <1 day/wk, 2 = 1 day/wk, 3 = 2–3 days/wk, 4 = 4–6 days/wk, 5=daily) with the severity (0=none, 1=very mild, 2=mild, 3=moderate, 4=moderately severe, 5=severe). The cutoff point used to define successful outcome after laparoscopic Heller myotomy was selected at the 75th percentile (upper quartile) of the entire cohort. Patients with dysphagia score falling above the cutoff point were classified into the unsuccessful outcome group (Nonresponders).

Operative Technique

Our technique for laparoscopic Heller myotomy has been previously described5. Briefly, after exposure of the anterior gastroesophageal (GE) junction, the myotomy is created by incising the distal 4–6 cm of esophageal musculature. The myotomy is extended 1–2 cm onto the gastric cardia using cautery scissors or an ultrasonic scalpel. Intraoperative endoscopy is performed before and simultaneously with the myotomy to assess the adequacy of the myotomy.

Statistical Analysis

The data are presented as mean ± SD for continuous variables and as counts or proportions (%) for categorical variables. Continuous variable means were compared by appropriate parametric or nonparametric tests. Categorical variables were compared with the Chi-square test. Statistical significance was set at P < 0.05.


The questionnaires were mailed to 160 patients and successfully received by 110 patients. One hundred patients returned the questionnaires with an overall response rate of 91%. The average postoperative follow-up was 3.3 years (range 12–120 months). The study cohort was constituted by 54 female and 46 male, with a mean age of 53 years. Laparoscopic Heller myotomy alone was performed in 67 patients and Dor fundoplication was added in 33 patients. As shown in Table 1, dysphagia and SF-36 scores were not affected by the addition of a Dor fundoplication.
Table 1

Effect of Dor-fundoplication on Dysphagia and SF-36 Scores


Heller myotomy (n = 67)

Heller-Dor (n = 33)


Dysphagia score

3.8 ± 2.8

2.9 ± 2.8


Total SF-36

74.7 ± 18.7

73.8 ± 20.8


SF-36 (PCS)

68.1 ± 20.8

70.7 ± 21.8


SF-36 (MCS)

76.5 ± 17.4

72.9 ± 21.1


There was a significant inverse correlation between dysphagia score and mental component (Pearson r = −0.379; P = 0.0001) and total SF-36 (Pearson r = −0.328; P = 0.001) scores.

As shown in Fig. 1, patients were considered to have a successful outcome after laparoscopic Heller myotomy when their postoperative dysphagia score was ≤ 5 (first to 74th percentile). According to this cutoff dysphagia score, 77 patients were included in the Responder group and 23 patients were classified in the Nonresponder group.
Figure 1

Dysphagia score distribution and according classification of the two groups (white bar: responder; black bar nonresponders).

Table 2 illustrates that there were no differences between the two groups in terms of mean age, gender distribution, rate of fundoplication, and length of postoperative follow-up.
Table 2

Demographic and Operative Data of the Two Groups


Responders (n = 77)

Nonresponders (n = 23)



54.9 ± 14.9

50.1 ± 13.2



42 female, 35 male

12 female, 11 male



27 Dor (35%)

6 Dor (26%)



40 ± 22 months

40 ± 22 months


As shown in Fig. 2, the Responder group had a significant higher (P < 0.05) mental component (MCS) and total SF-36 scores than Nonresponder group.
Figure 2

Mean SF-36 scores of the two groups (*P < 0.05).

Figure 3 shows the eight domains of the SF-36 score. Successful relief of dysphagia after laparoscopic Heller myotomy was associated with health-related QoL scores that were 13 points higher in Vitality (P < 0.05), 11 points higher in mental health (P < 0.05), and 12 points higher in General Health (P < 0.05).
Figure 3

SF-36 domain scores of the two groups (*P < 0.05).

Overall patient satisfaction with surgical outcome was 92%, with only eight patients not satisfied with the surgery.


Our study has demonstrated that laparoscopic Heller myotomy offers excellent long-term relief of achalasia-related symptoms resulting in a significant improvement of health-related QoL and patient’s perceived satisfaction.

Current treatments for achalasia, whether medical or surgical, cannot restore normal esophageal motility. Therefore, all the therapeutic options, including endoscopic botulinum toxin injection and pneumatic dilation of the LES are aimed to improve subjective symptoms6,7. The main drawback of these treatments is their transient effect on dysphagia. Differently, laparoscopic Heller myotomy is a durable and effective treatment for achalasia8,9.

Patients with achalasia are greatly affected by their disease. They commonly experience loss of physical strength, fatigue, frustration, and even strains in personal relationships. Many studies have showed that QoL and gastrointestinal symptoms related to achalasia improve significantly after laparoscopic Heller myotomy4,10, 11, 12, 13, 14. However, our study was the first to assess long-term QoL and to correlate better health-related QoL with successful relief of dysphagia.

The present study finds that dysphagia score is inversely correlated with total and mental health SF-36 scores. This finding confirms the observation previously made by Mineo and collaborators15. In their study, four-year dysphagia score was inversely correlated with postoperative changes in mental health. A plausible explanation for this observation is that the loss of normal swallowing and diet increases depression-related symptoms that directly affect the mental component of the SF-36 score16. Therefore, the finding of higher mean SF-36 mental score in the responder group is not surprising. In this group, the most significant improvements were seen in domains such as mental health and vitality. Similarly, Perrone and collaborators found significant postmyotomy improvements in domains affecting the mental SF-36 score, such as social function, and role limitations due to emotional problems17.

In patients with achalasia, it is very difficult to objectively assess the results of surgery because of the low incidence of the disease and the cost of the postoperative studies. In addition, patients are reluctant to undergo invasive testing, especially when they are satisfied with the surgical outcome. So we often rely on the patient’s assessment of their symptoms in determining the outcome of the surgery. This also has its downside, mainly because patients with achalasia often modify their diet to avoid symptoms of dysphagia, which may overestimate the therapeutic effectiveness of the myotomy. In addition, some studies have found no relationship between objective outcome measures and subjective measures12,18, 19, 20. Therefore, we need to highlight more the importance of instruments aimed to objectively assess surgical outcome from the patient’s perspective. SF-36 is a well-validated instrument that has been already used to evaluate surgical outcome. However, it is desirable to develop a valid and reliable measure of disease-specific health-related QoL. Recently, Urbach et al. developed a 10-item measure of disease-specific health-related QoL that sampled the concepts of food tolerance, dysphagia-related behavior modifications, pain, heartburn, distress, lifestyle limitation, and satisfaction21.

We were unable to implement this new instrument because our study was already ongoing at the time of the publication. However, future studies will benefit from using this disease-specific QoL instrument.

Our study also inquired about patient’s satisfaction. Among the 100 patients enrolled in the study, 92 were satisfied with the surgery and only six will not undergo surgery again. However, only 30 patients think that they were cured by surgery. On the other hand, successful relief of dysphagia, measured by dysphagia score, was observed in 77% of patients. This discrepancy can be explained by the fact that self-perceived outcomes measured by binary endpoints (i.e., yes/not) generally overestimate successful outcome when compared with continuous variable endpoints (i.e., Likert scale).

In conclusion our study demonstrated that successful relief of dysphagia after laparoscopic Heller myotomy for achalasia leads to an overall improvement in health-related QoL.


  1. 1.
    Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am 2001;11:235–248.PubMedGoogle Scholar
  2. 2.
    Howard PJ, Maher L, Pryde A, Cameron EW, Heading RC. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992;33:1011–1015.PubMedGoogle Scholar
  3. 3.
    Richards WO, Torquati A, Lutfi R. The current treatment of achalasia. Adv Surg 2005;39:285–314.PubMedCrossRefGoogle Scholar
  4. 4.
    Ben-Meir A, Urbach DR, Khajanchee YS, Hansen PD, Swanstrom LL. Quality of life before and after laparoscopic Heller myotomy for achalasia. Am J Surg 2001;181:471–474.PubMedCrossRefGoogle Scholar
  5. 5.
    Torquati A, Richards WO, Holzman MD, Sharp KW. Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases. Ann Surg 2006;243:587–593.PubMedCrossRefGoogle Scholar
  6. 6.
    Pandolfino JE, Howden CW, Kahrilas PJ. Motility-modifying agents and management of disorders of gastrointestinal motility. Gastroenterology 2000;118:S32–S47.PubMedCrossRefGoogle Scholar
  7. 7.
    Allescher HD, Storr M, Seige M, et al. Treatment of achalasia: botulinum toxin injection vs. pneumatic balloon dilation. A prospective study with long-term follow-Up. Endoscopy 2001;33:1007–1017.PubMedCrossRefGoogle Scholar
  8. 8.
    Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 1999;230587–593; discussion 593–584.PubMedCrossRefGoogle Scholar
  9. 9.
    Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004;240:405–412; discussion 412–405.PubMedCrossRefGoogle Scholar
  10. 10.
    Raftopoulos Y, Landreneau RJ, Hayetian F, et al. Factors affecting quality of life after minimally invasive Heller myotomy for achalasia. J Gastrointest Surg 2004;8:233–239.PubMedCrossRefGoogle Scholar
  11. 11.
    Decker G, Borie F, Bouamrirene D, et al. Gastrointestinal quality of life before and after laparoscopic heller myotomy with partial posterior fundoplication. Ann Surg 2002;236:750–758; discussion 758.PubMedCrossRefGoogle Scholar
  12. 12.
    Gholoum S, Feldman LS, Andrew CG, et al. Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia. Surg Endosc 2006;20:214–219.PubMedCrossRefGoogle Scholar
  13. 13.
    Yamamura MS, Gilster JC, Myers BS, et al. Laparoscopic heller myotomy and anterior fundoplication for achalasia results in a high degree of patient satisfaction. Arch Surg 2000;135:902–906.PubMedCrossRefGoogle Scholar
  14. 14.
    Mineo TC, Ambrogi V. Long-term results and quality of life after surgery for oesophageal achalasia: one surgeon’s experience. Eur J Cardio-thorac Surg 2004;25:1089–1096.CrossRefGoogle Scholar
  15. 15.
    Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg 2004;128:402–407.PubMedCrossRefGoogle Scholar
  16. 16.
    Ekberg O, Hamdy S, Woisard A, et al. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Dysphagia 2002;17:139–146.PubMedCrossRefGoogle Scholar
  17. 17.
    Perrone JM, Frisella MM, Desai KM, Soper NJ. Results of laparoscopic Heller-Toupet operation for achalasia. Surg Endosc 2004;18:1565–1571.PubMedCrossRefGoogle Scholar
  18. 18.
    Ponce M, Ortiz V, Juan M, et al. Gastroesophageal reflux, quality of life, and satisfaction in patients with achalasia treated with open cardiomyotomy and partial fundoplication. Am J Surg 2003;185:560–564.PubMedCrossRefGoogle Scholar
  19. 19.
    Burpee SE, Mamazza J, Schlachta CM, et al. Objective analysis of gastroesophageal reflux after laparoscopic heller myotomy: an anti-reflux procedure is required. Surg Endosc 2005;19:9–14.PubMedCrossRefGoogle Scholar
  20. 20.
    Gorodner MV, Galvani C, Fisichella PM, Patti MG. Preoperative lower esophageal sphincter pressure has little influence on the outcome of laparoscopic Heller myotomy for achalasia. Surg Endosc 2004;18:774–778.PubMedCrossRefGoogle Scholar
  21. 21.
    Urbach DR, Tomlinson GA, Harnish JL, et al. A measure of disease-specific health-related quality of life for achalasia. Am J Gastroenterol 2005;100:1668–1676.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Yassar Youssef
    • 1
  • William O. Richards
    • 1
  • Kenneth Sharp
    • 1
  • Michael Holzman
    • 1
  • Nikilesh Sekhar
    • 1
  • Joan Kaiser
    • 1
  • Alfonso Torquati
    • 1
  1. 1.Department of SurgeryVanderbilt University School of MedicineNashvilleUSA

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