Laparoscopic Heller Myotomy with Dor Fundoplication for Achalasia
Laparoscopic Heller myotomy with Dor fundoplication is an excellent surgical treatment for achalasia, achieving 90% symptom-free rates at 5 years with durable improvement in dysphagia, regurgitation, and quality of life. 1, 2
Surgical Technique and Rationale
The procedure requires complete surgical isolation of the esophagogastric junction through division of the phrenoesophageal ligament and short gastric vessels to accurately identify the gastroesophageal junction. 3 The myotomy must divide both circular and longitudinal muscle layers of the lower esophageal sphincter to relieve outflow obstruction. 3
The addition of Dor fundoplication is essential and should always be performed with Heller myotomy. 4 While the fundoplication slightly reduces myotomy adequacy (raising residual LES pressure from 1.8 to 4.6 mm Hg), it dramatically reduces gastroesophageal reflux without impairing esophageal emptying. 4 Specifically, upright reflux time decreases from 2.9% to 0.4%, and supine reflux time drops from 5.8% to 0%. 4 This balance between adequate emptying and reflux prevention makes Heller myotomy with Dor fundoplication superior to myotomy alone. 4
Clinical Outcomes and Durability
The procedure demonstrates excellent long-term efficacy:
- 90% actuarial probability of remaining symptom-free over 5 years 2
- 92.4% improvement in dysphagia 5
- Significant reduction in esophageal diameter on barium studies 1, 2
- Preserved quality of life improvement extending to 11 years postoperatively 1
The operation can be completed laparoscopically in 94% of cases with median operative time of 150 minutes. 2 Postoperative complications occur in approximately 6% of patients. 2
Important Caveats and Long-Term Considerations
GERD symptoms recur in a significant proportion of patients beginning 3-5 years postoperatively, despite the protective effect of Dor fundoplication. 1 Postoperative reflux affects up to 58% of patients, with erosive esophagitis developing in 8.8% on endoscopy and abnormal pH monitoring in 8.6%. 3, 5 This necessitates specific postoperative management strategies.
Treatment failures occur in approximately 8% of patients who develop persistent dysphagia or chest pain. 2 Seven of eight such patients in one series required pneumatic dilatation, which was successful in six cases, avoiding the need for reoperation. 2
Postoperative Management Protocol
Mandatory 8-week course of proton pump inhibitor therapy is required to promote mucosal healing. 3, 6 Given the high reflux rates (up to 58%), consider indefinite PPI therapy as erosive esophagitis develops in 23-48% without adequate acid suppression. 3
Aggressive antiemetic therapy with 5-HT3 receptor antagonists plus dexamethasone is critical because postoperative vomiting can disrupt the myotomy repair site and displace the fundoplication. 3
Dietary advancement should progress from clear liquids to full liquids for 5-7 days, then to 5-6 small meals daily of low-fiber, low-fat solid foods. 6
Comparison to POEM
While per-oral endoscopic myotomy (POEM) is now available as an alternative, POEM should be considered comparable to laparoscopic Heller myotomy for most achalasia subtypes when expertise is available. 7 POEM is specifically preferred for type III achalasia where longer myotomy is indicated. 7 However, POEM carries substantially higher reflux risk (odds ratio 9.31 for erosive esophagitis compared to LHM) despite avoiding esophagogastric junction dissection. 8
The choice between procedures should consider Chicago Classification subtype, local expertise (POEM requires 20-40 procedures to achieve competence), and patient willingness to accept higher reflux rates with POEM. 7