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

Abstract

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. 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). 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. 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.