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. 2023 Mar;37(3):1742-1748.
doi: 10.1007/s00464-022-09696-8. Epub 2022 Oct 10.

Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia

Renato Salvador #  1 , Giulia Nezi #  2 , Francesca Forattini  2 , Federica Riccio  2 , Arianna Vittori  2 , Luca Provenzano  2 , Giovanni Capovilla  2 , Loredana Nicoletti  2 , Lucia Moletta  2 , Elisa Sefora Pierobon  2 , Michele Valmasoni  2 , Stefano Merigliano  2 , Mario Costantini  2
Affiliations

Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia

Renato Salvador et al. Surg Endosc. 2023 Mar.

Abstract

Background: The end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of this study was to examine the outcome of Laparoscopic Heller-Dor in patients with end-stage achalasia, comparing them with patients who had mega-esophagus without a sigmoid shape.

Methods: From 1992 to 2020, patients with a diagnosis of sigmoid esophagus, or radiological stage IV achalasia (the SE group), and patients with a straight esophagus larger than 6 cm in diameter, or radiological stage III achalasia (the NSE group), were all treated with LHD. The two groups were compared in terms of patients' symptoms, based on the Eckardt score, and on barium swallow, endoscopy and manometry performed before and after the treatment. The failure of the treatment was defined as an Eckardt score > 3, or the need for further treatment.

Results: The study involved 164 patients: 73 in the SE group and 91 in the NSE group. No intra- or postoperative mortality was recorded. The median follow-up was 51 months (IQR 25-107). The outcome was satisfactory in 71.2% of patients in the SE group, and in 89% of those in the NSE group (p = 0.005).

Conclusions: SE is certainly the worst condition of the disease and the final outcome of LHD, in term of symptom control, is inferior compared to NSE. Despite this, almost 3/4 of the SE patients experienced a significant relieve in symptoms after LHD, which may therefore still be the first surgical option to offer to these patients, before considering esophagectomy.

Keywords: Achalasia; End-stage achalasia; Laparoscopic Heller-Dor; Sigmoid esophagus.

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Conflict of interest statement

Renato Salvador, Giulia Nezi, Francesca Forattini, Federica Riccio, Arianna Vittori, Luca Provenzano, Giovanni Capovilla, Loredana Nicoletti, Lucia Moletta, Elisa Sefora Pierobon, Michele Valmasoni, Stefano Merigliano, Mario Costantini have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
The pull-down technique: the esophagus is isolated from the pillars and the dissection is extended about 10 cm upwards. The surgeon applies two or more stitches on each side of the esophageal wall to anchor it to the pillars
Fig. 2
Fig. 2
Kaplan–Meier curves for a positive outcome in the two groups: the probability of end-stage achalasia patients having a persistently good outcome after LHD was higher than 71% at 9 years after surgery. *Success was defined as Eckard score < 3 and no need for further treatment
Fig. 3
Fig. 3
Pre- and post-operative barium swallows using the pull-down technique
Fig. 4
Fig. 4
Kaplan–Meier curves for a positive outcome in end-stage achalasia patients after classic LHD and LHD with the pull-down technique. *Success was defined as Eckard score < 3 and no need for further treatment
See this image and copyright information in PMC

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