Laparoscopic Heller myotomy and Dor fundoplication – a contemporary solution for achalasia
DOI:
https://doi.org/10.5281/zenodo.16978984Keywords:
Achalasia, Heller myotomy, Dor fundoplication, Laparoscopy, POEMAbstract
Background:
Achalasia is a rare esophageal motility disorder characterized by absent peristalsis and impaired lower esophageal sphincter (LES) relaxation. Several therapeutic options exist, but laparoscopic Heller myotomy (LHM) combined with partial fundoplication remains the gold standard.
Case Presentation:
We report a 52-year-old male with progressive dysphagia, regurgitation, and reflux, with a prior history of emergency Billroth I gastrectomy for a perforated pyloric ulcer. The patient had been followed in the gastroenterology clinic and underwent several endoscopic balloon dilatations. Initially effective, dilatations became increasingly short-lived, and during the last session, no relief was achieved, with impossible passage with the endoscope. At presentation, he reported extreme esophageal dilatation, frequent regurgitation of stagnant food, and nocturnal choking episodes. Laparoscopic Heller myotomy with Dor fundoplication was performed. The postoperative course was uneventful, with complete resolution of symptoms and no reflux.
Discussion:
Balloon dilatation yields good short-term results but is associated with a risk of recurrence and complications. Failure is usually defined by persistent dysphagia, rapid relapse, repeated procedures, or complications. In such cases, LHM offers durable symptom relief with low morbidity and mortality. Myotomy alone increases the risk of reflux, which is significantly reduced when combined with partial fundoplication.
Conclusion:
Laparoscopic Heller myotomy with Dor fundoplication remains a safe and effective treatment, even in patients with prior upper gastrointestinal surgery.
References
1. Kavanagh R, Nau P. Laparoscopic Heller myotomy—A review of the literature. J Xiangya Med. 2019;4:12.
2. Litle VR. Laparoscopic Heller myotomy for achalasia: a review of the controversies. Ann Thorac Surg. 2008;85(2 Suppl):S743-S746.
3. Ramacciato G, D’Angelo FA, Aurello P, et al. Laparoscopic Heller myotomy with or without partial fundoplication: a matter of debate. World J Gastroenterol. 2005;11(10):1558-1561.
4. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240(3):405-415.
5. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271.
6. Schlottmann F, Luckett DJ, Fine J, Shaheen NJ, Patti MG. Laparoscopic Heller Myotomy Versus POEM: A Systematic Review and Meta-analysis. Ann Surg. 2018;267(3):451-460.
7. Donahue PE, Horgan S, Liu KJ, Madura JA. Floppy Dor fundoplication after esophagocardiomyotomy for achalasia. Surgery. 2002;132(4):716-723.
8. Podboy AJ, et al. Long-term outcomes of POEM and laparoscopic Heller myotomy: similar efficacy and reflux rates after approximately 4 years. Am J Surg. 2021;221(6):1151-1157.
9. Sobral J, Machado M, Barbosa JP, Barbosa J. Achalasia: Laparoscopic Heller myotomy with fundoplication versus POEM – systematic review and meta-analysis. Esophagus. 2024;21(3):298-305.
10. Sürmelioğlu A. Long-term results of laparoscopic Heller myotomy with Dor fundoplication: symptom relief and esophagitis-free survival. J Surg Med. 2021;5(3):981-343.
11. Hugova K, Mares J, Hakanson B, et al. POEM vs LHM+Dor in idiopathic achalasia: 5-year multicentre RCT. Lancet Gastroenterol Hepatol. 2025;10:xxx-xxx.
12. Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am. 2001;11(2):235-245.
