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Long-term outcomes of laparoscopic Heller’s myotomy with angle of His accentuation in patients of achalasia cardia

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Abstract

Background

Laparoscopic Heller’s myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia.

Methods

One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan–Meier analysis.

Results

At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan–Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years.

Conclusions

LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor’s or Toupet’s fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.

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Acknowledgements

I want to acknowledge Dr Rahul Kumar Jaiswal for his help in this work.

Funding

There was no funding needed for this study.

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Authors and Affiliations

  1. Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India

    Sonali Mittal, Aditya Kumar, Suhani Suhani, Mohit Joshi & Hemanga K. Bhattacharjee

  2. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India

    Deepak Gunjan

  3. Department of Physiology, All India Institute of Medical Sciences, New Delhi, India

    Ritesh Kumar Netam & Abhijith K. Anil

  4. Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

    Raju Sharma

  5. Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 419, 4th Floor, Surgery Block, New Delhi, 110029, India

    Rajinder Parshad

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  1. Sonali Mittal
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Correspondence to Rajinder Parshad.

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Sonali Mittal, Aditya Kumar, Deepak Gunjan, Ritesh Kumar Netam, Abhijith K Anil, Suhani Suhani, Mohit Joshi, Hemanga K Bhattacharjee, Raju Sharma, or Rajinder Parshad have no conflicts of interest or financial ties to disclose.

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Mittal, S., Kumar, A., Gunjan, D. et al. Long-term outcomes of laparoscopic Heller’s myotomy with angle of His accentuation in patients of achalasia cardia. Surg Endosc 38, 659–670 (2024). https://doi.org/10.1007/s00464-023-10571-3

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