Circumferential Heller myotomy can relieve chest pain in patients with achalasia: a prospective clinical trial

Abstract

Background: Noncardiac chest pain often coexists with dysphagia in patients diagnosed with achalasia. The current standard treatment for achalasia, laparoscopic Heller myotomy with Dor fundoplication, has an insufficient effect on noncardiac chest pain. The aim of this study is to investigate the efficacy of circumferential Heller myotomy on esophageal chest pain in patients with achalasia.

Methods: Twenty patients diagnosed with achalasia who complained of noncardiac chest pain were recruited and underwent circumferential Heller myotomy. Using an institutional achalasia database, we randomly selected 60 patients who underwent standard laparoscopic Heller myotomy with Dor fundoplication, based on a 3-to-1 propensity score-matching analysis. We compared surgical outcomes between the circumferential Heller myotomy and the laparoscopic Heller myotomy with Dor fundoplication groups.

Results: Patients undergoing circumferential Heller myotomy had a higher rate of postoperative noncardiac chest pain relief than the laparoscopic Heller myotomy with Dor fundoplication group [95% (19/20) vs. 75% (45/60), p = 0.045]. No differences in dysphagia and vomiting were found between groups (p = 0.783 and p = 0.645, respectively). Patients in the circumferential Heller myotomy group had significantly better esophageal clearance. The prevalence of reflux endoscopic esophagitis was higher in the circumferential Heller myotomy group than in the control group [35.0% (7/20) vs. 10.0% (6/60), p = 0.015].

Conclusions: There is promising early evidence that circumferential Heller myotomy may be effective in the treatment of achalasia-related chest pain. Further research, including larger randomized studies with long-term follow-up, is warranted.

Keywords: Achalasia; Chest pain; Dor fundoplication; Heller myotomy.