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Comparative Study
. 2025 May;39(5):3328-3336.
doi: 10.1007/s00464-025-11661-0. Epub 2025 Apr 15.

Heller myotomy in patients with prior endoscopic interventions vs the treatment-naïve

Nethra Jain  1 , John O Barron  1 , Andrew J Toth  2 , Monisha Sudarshan  1 , Madhusudhan Sanaka  3 , Sadhvika Ramji  1 , Saurav Adhikari  1 , Sudish C Murthy  1 , Eugene H Blackstone  1   2 , Siva Raja  4 ; Cleveland Clinic Esophageal Research Group
Collaborators, Affiliations
Comparative Study

Heller myotomy in patients with prior endoscopic interventions vs the treatment-naïve

Nethra Jain et al. Surg Endosc. 2025 May.

Abstract

Background: Definitive palliation for achalasia is surgical myotomy; however, patients frequently undergo endoscopic treatments prior to myotomy. Surgeons may perceive myotomy to be more challenging after prior treatments, due to scarring and fusion of dissection planes, but outcomes compared to the treatment-naïve remain unclear. Hence, we compared institutional Heller myotomy outcomes in patients who underwent pre-myotomy endoscopic treatments to those who did not.

Methods: From 1/1/2010 to 1/1/2020, 436 patients underwent Heller myotomy for achalasia at Cleveland Clinic, 101 (23%) of whom had prior endoscopic intervention(s): 39 (39%) pneumatic dilation, 57 (56%) botulinum toxin injection, and 5 (4.9%) both (Prior group). Propensity score matching generated two groups of 101 pairs. Short-term outcomes and longitudinal postoperative symptom palliation (Eckardt score ≤ 3), esophageal emptying at five minutes, and reintervention were assessed and compared with the treatment-naïve (Naïve group).

Results: There were no statistically significant differences in operative time, mucosal perforation, or length of stay between Prior and Naïve groups (P > .12). At 5 years, the probability of symptom palliation was 83% in the Prior Group vs 81% in the Naïve Group (P = .63) and complete esophageal emptying 23% vs 32% (P = .095). The cumulative number of reinterventions per 100 patients at 10 years was 7.9 in the Prior Group and 4.8 in the Naïve Group (P = .13).

Conclusion: The perception of increased complexity of Heller myotomy in patients with prior endoscopic interventions does not translate to stastically significant differences in short- or long-term outcomes when compared to the treatment-naïve. A subtle longitudinal pattern of suboptimal esophageal emptying and increased reintervention for patients with prior intervention(s), suggests that, when possible, up-front myotomy may be preferred.

Keywords: Botulinum toxin; Esophageal achalasia; Heller myotomy; Pneumatic dilation.

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Conflict of interest statement

Declarations. Disclosures: Drs. Nethra Jain, John O. Barron, Monisha Sudarshan, Madhusudhan Sanaka, Sadhvika Ramji, Saurav Adhikari, Sudish C. Murthy, Eugene H. Blackstone, Siva Raja, Mr. Andrew J. Toth, and the Cleveland Clinic Esophageal Research Group Collaborators (Drs. Daniel P. Raymond, Prashanthi Thota, Scott L. Gabbard, and Mark E. Baker) have no relevant conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Adjusted longitudinal prevalence of complete TBE emptying at 5 min after Heller myotomy in patients with prior treatment (blue) vs the treatment-naïve (red). Solid lines represent the estimated model of complete emptying. Symbols represent actual data grouped over different time intervals without regard to the repeated observation, presented here as a crude verification of the model fit. The number of patients and TBEs available between are depicted below the graph (Color figure online)
Fig. 2
Fig. 2
Adjusted longitudinal prevalence of Eckardt score ≤ 3 after Heller myotomy in prior treatment (blue) vs treatment-naïve (red) groups. Solid lines depict parametric estimates of prevalence of Eckardt scores. Symbols represent actual data grouped over different time intervals without regard to the repeated observation, presented here as a crude verification of the model fit. The number of patients and Eckardt scores available between time points are depicted below the graph (Color figure online)
Fig. 3
Fig. 3
Cumulative number of reinterventions per 100 patients in the matched cohort. Blue represents patients with prior treatment and red patients who are treatment-naïve. Each circle represents a reintervention positioned by non-parametric estimate. Vertical bars represent asymmetric 68% confidence limits. Solid lines and dashes lines represent the parametric estimates and confidence intervals, respectively (Color figure online)
Fig. 4
Fig. 4
Hazard function for reintervention for matched patients with prior treatment (blue) vs patients who are treatment-naïve (red). Dashed bands represent 68% confidence intervals equivalent to 1 standard deviation (Color figure online)
See this image and copyright information in PMC

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