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. 2025 Jun 18:S0022-5223(25)00531-8.
doi: 10.1016/j.jtcvs.2025.06.011. Online ahead of print.

Heller myotomy for esophageal achalasia: Outcomes in 1010 patients with longitudinal follow-up

John O Barron  1 , Andrew J Toth  2 , Eugene H Blackstone  3 , Sadhvika Ramji  1 , Nethra Jain  1 , Sadia Tasnim  1 , Prashanthi N Thota  4 , Scott L Gabbard  4 , Andrea Zanoni  5 , Monisha Sudarshan  1 , Sudish C Murthy  1 , Siva Raja  6 ; Cleveland Clinic Esophageal Research Group
Collaborators, Affiliations

Heller myotomy for esophageal achalasia: Outcomes in 1010 patients with longitudinal follow-up

John O Barron et al. J Thorac Cardiovasc Surg. .

Abstract

Background: Achalasia is a rare progressive disease for which longitudinal outcomes and optimal follow-up remain poorly defined. We assessed longitudinal reintervention, symptom palliation, and esophageal emptying after Heller myotomy performed in more than 1000 patients over a 25-year period.

Methods: Between January 1, 1995, and January 1, 2020, a total of 1010 adults underwent Heller myotomy at Cleveland Clinic. The operation was minimally invasive in 937 (93%) patients, with Dor fundoplication in 838 (92%). Esophageal emptying was assessed by timed barium esophagram (TBE), and symptoms were quantified by Eckardt score. Multiphase mixed-effects models and Kaplan-Meier analysis were used to estimate longitudinal symptom palliation, esophageal emptying, and reintervention (pneumatic dilation ≥30 mm, per-oral endoscopic myotomy, repeat Heller myotomy, or esophagectomy).

Results: Freedom from any reintervention was 75% and freedom from esophagectomy was 96.8% at 10 years postmyotomy. The risk of reintervention was greatest during the first year, with 1 reintervention portending additional reintervention(s). Severe recurrent symptoms were rare, with a probability of freedom from severe dysphagia (daily or every meal) of 74% and probability of an Eckardt score ≤3 of 68% at 10 years. The probability of complete TBE emptying was 55% immediately postmyotomy and decreased to 24% by 10 years.

Conclusions: Heller myotomy provides long-term symptom palliation and esophageal emptying for patients with achalasia, with a gradually increasing risk of reinterventions over time, highlighting the importance of initial annual follow-up. After 3 years, the follow-up interval may be increased to every 3 years when symptom relief and esophageal emptying remain stable. These findings provide a long-term benchmark for future therapies.

Keywords: Eckardt score; Heller myotomy; esophageal achalasia; fundoplication; reintervention; timed barium esophagram.

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Conflict of interest statement

Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.