Surg Endosc
DOI 10.1007/s00464-009-0508-1
Laparoscopic Heller myotomy for achalasia: results after 10 years
Sarah M. Cowgill Æ Desiree Villadolid Æ
Robert Boyle Æ Sam Al-Saadi Æ Sharona Ross Æ
Alexander S. Rosemurgy II
Received: 15 May 2008 / Accepted: 16 December 2008
Ó Springer Science+Business Media, LLC 2009
Abstract
Background Laparoscopic Heller myotomy was first
undertaken in the early 1990s, and appreciable numbers of
patients with 10-year follow-up periods are now available.
This study was undertaken to determine long-term out-
comes after laparoscopic Heller myotomy used to treat
achalasia.
Methods Of 337 patients who have undergone laparo-
scopic Heller myotomy since 1992, 47 who underwent
myotomy more than 10 years ago have been followed
through a prospectively maintained registry. Among many
symptoms, patients scored dysphagia, chest pain, vomiting,
regurgitation, choking, and heartburn before and after
myotomy using a Likert scale with choices ranging from 0
(never/not bothersome) to 10 (always/very bothersome).
Symptom scores before and after myotomy were compared
using a Wilcoxon matched-pairs test. Data are reported as
median (mean ± standard deviation).
Results The median length of the hospital stay was 2 days
(mean, 3 ± 8.6 days; range, 1–60 days). Notable compli-
cations were infrequent after myotomy. There were no
Presented at the 2007 Society of American Gastrointestinal
Endoscopic Surgeons (SAGES) Scientific Session, 18–22 April 2007,
Las Vegas, NV, USA.
S. M. Cowgill
D. Villadolid
R. Boyle
S. Al-Saadi

S. Ross
A. S. Rosemurgy II
Digestive Disorders Center,
Tampa General Hospital, Tampa, FL, USA
S. M. Cowgill
D. Villadolid
R. Boyle
S. Al-Saadi

S. Ross
A. S. Rosemurgy II (&)
Division of General Surgery, University of South Florida
College of Medicine, Tampa General Hospital,
P.O. Box 1289, Room F145, Tampa, FL 33601, USA
e-mail: arosemur@hsc.usf.edu
perioperative deaths. One patient required a redo myotomy
after 5 years due to recurrence of symptoms. At this writing,
33 patients (70%) are still alive. The causes of death after
discharge were unrelated to myotomy. The frequency and
severity scores for dysphagia, chest pain, vomiting, regur-
gitation, choking, and heartburn all decreased significantly
after laparoscopic Heller myotomy (p \ 0.0001 for all).
Conclusions Laparoscopic Heller myotomy can be
undertaken with few complications. This procedure sig-
nificantly decreases the frequency and severity of achalasia
symptoms without promoting heartburn. The symptoms of
achalasia are durably ameliorated by laparoscopic Heller
myotomy during long-term follow-up evaluation, thereby
promoting application of this procedure.
Keywords Achalasia
Digestive
Esophageal

Laparoscopic Heller myotomy
Through the years, various methods used to relieve the
esophageal outlet obstruction of achalasia have included
blunt dilation, injection of the gastroesophageal junction
(GEJ), and operative decompression transthoracically or
transabdominally. Laparoscopic Heller myotomy, first
undertaken in the early 1990s, was described by Shimi
et al. [1]. Although patients with achalasia often are
referred to surgeons for a myotomy, sometimes after
undergoing years of pneumatic dilation, botulinum toxin
(BoTox) injections, or both, laparoscopic Heller myotomy
has gained acceptance as the intervention of choice for
treating achalasia [2–5].
Achalasia is a rare esophageal motility disorder affect-
ing an estimated 1 per 100,000 individuals a year [6]. Few
centers amass significant numbers of patients treated for
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achalasia. Treatment in the past has been scattershot, with
clinicians providing pneumatic dilations, Botox injections,
or combinations of the two before referral to surgeons.
Laparoscopic Heller myotomy provides a minimally inva-
sive approach to achalasia with durable and effective out-
comes [2].
Relieving the esophageal outlet obstruction ameliorates
symptoms of achalasia, but symptoms rarely disappear
completely. Patients often continue to have ongoing com-
plaints related to underlying esophageal dysmotility,
symptoms not amenable to palliation by myotomy. Since
1992, laparoscopic Heller myotomies have been offered,
and appreciable numbers of patients with 10-year follow-
up periods are now available.
This study was undertaken to determine the long-term
outcomes after laparoscopic Heller myotomy used to treat
achalasia. Our hypothesis was that laparoscopic Heller
myotomy offers excellent palliation of symptoms related to
achalasia with minimal immediate morbidity and durable
long-term efficacy.
Materials and methods
Since 1992, 337 patients have undergone laparoscopic
Heller myotomy and are followed in a prospectively
maintained database. Patient data collection and study
design were conducted in concordance with a protocol
approved by the Institutional Review Board of the Uni-
versity of South Florida College of Medicine.
Of the 337 patients, those who underwent laparoscopic
Heller myotomy 10 years or longer ago were identified.
Achalasia was firmly diagnosed for all patients by a timed
barium esophagram, esophagoscopy, and/or esophageal
manometry. Loss of esophageal peristalsis with failure of
coordinated lower esophageal sphincter (LES) relaxation
was documented by manometry.
Preoperatively, patients scored the frequency and
severity of their symptoms during their clinic visit using a
Likert scale with choices ranging from 0 (never/not both-
ersome) to 10 (always/very bothersome). Many symptoms
were queried. Among symptoms queried were dysphagia,
heartburn, chest pain, vomiting, choking, and regurgitation.
In addition, the patients scored the frequency and severity
of their symptoms after operative intervention. At the last
follow-up visit after operative intervention, the patients
reported their outcomes as excellent (complete resolution
of symptoms), good (symptoms once per month or less
frequently), fair (symptoms weekly or less frequently), or
poor (symptoms daily or more often or severe than before
myotomy). The patients graded their experience from very
satisfying to very unsatisfying. Finally, the patients were
asked whether they still would undergo the operation.
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Surg Endosc
Operative technique
All the patients underwent laparoscopic Heller myotomy.
This operation is performed using a five-port technique, as
previously described [7]. A 10-mm port is placed at the
umbilicus under direct visualization. A 10-mm port placed
with pneumoperitoneum and videoscopic guidance along
the right anterior axillary line at the subcostal margin is
used to insert a fan retractor. This retractor lifts the liver
away from the stomach and gastroesophageal junction.
The main working port is a 10-mm port placed near the
right midclavicular line along the subcostal margin.
Another 10-mm port is placed at the subxyphoid position,
through which a 0° scope is placed. Finally, a 5-mm port is
placed along the left subcostal margin to allow access for
the assistant.
First, the gastrohepatic ligament is opened widely in a
stellate fashion using an ultrasonic dissector. The dissec-
tion then is carried up and down the right and left crura and
into the mediastinum for adequate mobilization of the
esophagus into the peritoneal cavity. It generally is
unnecessary to divide short gastric vessels, but they are
divided if this aids in freeing the esophagus from the
esophageal hiatus and in starting the mediastinal dissection.
Once a sufficient length of esophagus has been mobilized
into the abdomen, the dissection is concluded. The gas-
trohepatic fat pad is routinely excised to expose the GEJ
optimally for myotomy. The myotomy is carried cephalad
and then caudad to stomach.
To confirm an adequate myotomy, intraoperative
endoscopy is routinely undertaken. An adequate myotomy
is confirmed when the endoscope passes easily into the
stomach, the gastroesophageal junction opens easily with
endoscopic air insufflation, and transillumination of the
myotomized segment confirms muscle division well above
and below the Z-line [8].
Early in our experience, fundoplications were selec-
tively constructed with Heller myotomies. Selectively, a
partial fundoplication was applied only if a patulous hiatal
defect was encountered, a large hiatal hernia was noted, or
an esophagotomy occurred [9]. Initially, 270° posterior
fundoplications were applied selectively except when
esophagotomy occurred, and then an anterior fundoplica-
tion was used to buttress the repair. Subsequently, sub-
jective concerns about dysphagia led to application of
anterior fundoplications. Later, anterior fundoplications
were constructed routinely after publication of a random-
ized trial supporting their application [10].
If an anterior fundoplication was used, the anterior
fundus was first sutured to the left side of the esophagus,
lateral to the myotomy. Then the anterior fundus was
sutured to the right side of the esophagus, again lateral to
the myotomy. In this manner, nearly, but not all the
Surg Endosc
myotomized esophagus was covered by the anterior fun-
doplication. The esophageal hiatus then was reconstructed
using 0-braided polyester suture. Next, the anterior fundus
was tacked to the right crus to avoid twisting of the
esophagus and to minimize tension on the fundus, which
could cause the fundoplication to come undone. The fascia
at each trocar site was closed with monofilament absorb-
able suture, and the skin was closed with paper strips.
Postoperative management
With transfer out of the postanesthesia recovery unit,
patients underwent esophagography to ensure adequate
esophageal emptying and absence of esophagotomy/gas-
trotomy. With prompt emptying and no leak, patients were
started on liquid oral diets. They generally were discharged
the next morning with instructions to continue a liquid diet
until a follow-up visit in 1–2 weeks. At that time, their
diets were advanced to a more textured diet. If the post-
operative esophagram indicated poor esophageal emptying,
it usually was due to self-limited postoperative edema that
resolved within 24–48 h. If evidence of poor emptying did
not resolve quickly, the possibility of an incomplete
myotomy was considered.
Patients were seen at the clinic within 2 weeks of dis-
charge, then followed with clinic visits annually as out-
patients. The patients determined the frequency and
severity of their symptoms at each encounter, as stated
previously.
Data management and statistical analysis
Data were maintained on an Excel spreadsheet (Microsoft,
Redmond, WA, USA). The data were analyzed by Wilco-
xon matched-pairs test and Mann–Whitney U test when
appropriate, using True Epistat (Epistat Services, Rich-
ardson, TX, USA) or GraphPad InStat (GraphPad Soft-
ware, San Diego, CA, USA). Significance was accepted
Fig. 1 The frequencies of all
achalasia symptoms scored
were significant, but dysphagia
was particularly troubling
preoperatively. Postoperatively,
0 (never) to 10 (always)
Median Likert Score
during an extended follow-up
period, the frequency of
symptoms continue to be
ameliorated
with 95% confidence. Where, appropriate, data are pre-
sented as median (mean ± standard deviation).
Results
Of the 337 patients who have undergone laparoscopic
Heller myotomy since 1992, 47 had laparoscopic myotomy
10 or more years ago. Of these 47 patients, 26 (55%) are
men with a median age of 49 years (mean,
52 ± 19.2 years; range, 18–85 years). The median duration
of symptoms before laparoscopic Heller myotomy was
4 years (mean, 7 ± 6.3 years).
Before laparoscopic Heller myotomy, 38 patients (81%)
had endoscopic interventions for achalasia, with 9 under-
going pneumatic dilation, 10 undergoing botulinum toxin
injection, and 19 undergoing both. One patient had three
Botox injections before referral for a laparoscopic Heller
myotomy. Another had seven pneumatic dilations before
undergoing a laparoscopic Heller myotomy.
Before laparoscopic Heller myotomy, symptom severity
and frequency were scored by the patients. Preoperatively,
the frequency of dysphagia was particularly bothersome to
patients, but all symptoms were scored high. The preop-
erative severity of dysphagia, choking, vomiting, and
regurgitation were scored high, but, again, preoperative
chest pain and heartburn were severe as well (Figs. 1, 2).
All Heller myotomies were attempted and completed
laparoscopically. Nine patients underwent concomitant
procedures at the time of laparoscopic Heller myotomy
including one anterior fundoplication, four Toupet fundo-
plications, one concomitant diverticulectomy, one para-
thyroidectomy, one umbilical hernia repair, and one
cholecystectomy. The median length of the hospital stay
was 2 days (mean, 3 ± 8.6 days; range, 1–60 days).
Complications or inadvertent intraoperative events did
occur. One patient required a small tube thoracostomy for a
Before Myotomy
Frequency of Symptoms After Myotomy
*(p<0.01, Wilcoxon matched pairs test)
10
9
8
7
6
5 *
4
3 * * * * *
2
1
0
Dysphagia Choking Vomiting Regurgitation Chest Pain Heartburn
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 Surg Endosc

Fig. 2 Severity levels of Before Myotomy

dysphagia, choking, vomiting, Severity of Symptoms
*(p<0.01, Wilcoxon matched pairs test) After Myotomy
and regurgitation all were
10

0 (not bothersome) to 10 (very

notable preoperatively, and all
improved significantly during 9

Median Likert Score

an extended follow-up period 8

bothersome)
7
6
5
4
3 * *
2 * * *
1 *
0
Dysphagia Choking Vomiting Regurgitation Chest Pain Heartburn

carbon dioxide pneumothorax, and one patient had a pro-
longed hospital stay due to urinary retention.
Seven patients experienced a prolonged stay ([24 h)
secondary to delayed esophageal emptying after myotomy,
seemingly due to postoperative edema at the GEJ docu-
mented on postoperative esophagography. The median
length of stay for these seven patients was 3.7 days, and all
had resolution of delayed esophageal emptying.
Two patients in this cohort experienced significantly
more complicated hospital courses after laparoscopic Hel-
ler myotomy. The first patient with a significantly pro-
longed stay was a septuagenarian with chronic obstructive
pulmonary disease and coronary artery disease who
required extensive lysis of adhesions at the initial opera-
tion. On postoperative day 5, when he failed to progress, an
enterocutaneous fistula was identified at the proximal
jejunum, and he underwent an open repair of the fistula.
Prolonged respiratory failure after this complication led to
tracheostomy placement, but the patient was subsequently
discharged after 60 days in the hospital.
The second patient, an 18-year-old woman, underwent a
laparoscopic Heller myotomy in 1995 but experienced
unexplained acute renal failure and respiratory failure
without evidence of a leak on radiologic studies. Ulti-
mately, she recovered but had a complicated course,
requiring a ‘‘redo’’ open myotomy. At this writing, she
continues to report symptoms related to profound esopha-
geal dysmotility. To date, no patient in this population has
undergone an esophagectomy for end-stage achalasia.
Postoperatively, all symptoms uniformly and signifi-
cantly improved in frequency and severity (Figs. 1, 2)
(p \ 0.01 for all symptoms, Wilcoxon matched-pairs test).
The frequency of dysphagia postoperatively continued to
be scored relatively high. However, it significantly
improved from preoperative scoring. The frequency and
severity of heartburn symptoms, although present, also
significantly improved after laparoscopic Heller myotomy.
Most of the patients (92%) reported symptom control
overall to be good or excellent (Fig. 3), and 92% of the
Fair Poor
8% 0%
Excellent
42%
Good
50%
Fig. 3 Patients were asked to grade their current symptoms com-
pared with before their operation as excellent (symptoms completely
resolved), good (symptoms less than once per month), fair (symptoms
less than once per week), or poor (symptoms not improved)
patients undergoing laparoscopic Heller myotomy reported
their experience overall to be satisfying or very satisfying
(Fig. 4).
Of the 47 patients, 6 underwent some form of endo-
scopic intervention for achalasia postoperatively, with 2
undergoing pneumatic dilation, 2 undergoing botulinum
toxin injection, and 2 undergoing both.
Of the 47 patients, 33 are still alive at this writing. The
14 patients who died did not experience perioperative
deaths. One patient died of complications associated with
congestive heart failure, and one patient died of pneumo-
nia. The cause of death for the remaining 12 patients is
unknown, but it is believed that neither achalasia nor lap-
aroscopic Heller myotomy played a role in their deaths.
For nine patients, current contact has been lost, although
follow-up evaluation beyond short term was obtained for
all. The median follow-up period was 10.6 years (mean,
10.9 ± 1.1 years).

123
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Very
Unsatisfying Unsatisfying
8% 0%
Neither
0%
Satisfying
29%
Very Satisfying
63%
Fig. 4 Patients were asked to grade their overall experience
Discussion
Surgeons and most clinicians do not have the opportunity
to see significant numbers of patients with a diagnosis of
achalasia. Often, the failure to recognize and diagnose
achalasia expediently means the process to definitive
treatment can be a chronic, vexing problem for both the
naı̈ve clinician and the patient experiencing the symptoms.
Chronicity of the dysmotility integral to achalasia can
lead to lifelong complaints from the patient regardless of
medical or surgical intervention. In the short term, certainly,
a Heller myotomy is in the armamentarium of therapy for
patients with achalasia, but the question is whether the
chronicity of the condition and the palliative nature of the
operation lead to long-term satisfaction for these patients.
Due to the chronicity of achalasia and the very nature of the
operation indicated to palliate it (i.e., operating on the
tenuous tissues of the esophagus), evidence of beneficial
symptomatic outcomes might be expected to diminish over
time. This study documents the course of patients followed
since laparoscopic Heller myotomies were first described in
1991 and confirms that laparoscopic Heller myotomy is a
safe, durable mode of alleviating the esophageal outlet
obstruction of achalasia in the long term.
A relatively gender-equal population of middle-aged
individuals has been followed after laparoscopic Heller
myotomy. Many had reported symptoms related to acha-
lasia of more than 4 years duration, and many had under-
gone prior endoscopic attempts to alleviate the esophageal
obstruction of achalasia with little to no long-term relief.
All reported significant dysphagia and regurgitation, but
certainly choking, vomiting, chest pain, and heartburn also
were scored high in this group of patients before laparo-
scopic Heller myotomy.
All the patients underwent a laparoscopic Heller myot-
omy with no conversions to celiotomy. Generally, after
documentation of contrast promptly flowing from
esophagus to stomach with no extraluminal leak in the
postoperative esophagram, patients could tolerate a liquid
or soft diet and were discharged within 24 h. The median
length of hospital stay was 2 days. However, early in the
experience with laparoscopic Heller myotomy, surgeons
experienced less security in sending the patients home on
postoperative day 1. As experience with the operation
increased and hospital discharge issues became more
important in medicine, most patients were discharged
within the first 24 h after laparoscopic Heller myotomy.
The most commonly identified cause of prolonged
hospital stay in this cohort was narrowing at the GEJ
secondary to postoperative edema. In all seven patients,
this edema resolved. A repeat esophagram demonstrated
appropriate flow of contrast into the stomach, and the
patients were discharged soon after demonstrating toler-
ance of an oral diet.
Although no perioperative deaths occurred, 2 of the 47
patients sustained serious complications. The first patient,
an elderly gentleman, had an extensive lysis of adhesions
in association with his myotomy and experienced sepsis
and respiratory failure secondary to an enterocutaneous
fistula. He subsequently recovered and at this writing
reports amelioration of his achalasia.
The second patient, 18 years old when her achalasia was
diagnosed, underwent a laparoscopic Heller myotomy. No
enteric leak was identified, but the patient became pro-
foundly ill, experienced renal failure, and required moni-
toring in the intensive care unit soon after operative
intervention. Continued symptoms after recovery and
radiologic evidence of an incomplete myotomy led to a
reoperative myotomy, with increased extension onto the
gastric cardia. At this writing, 12 years later, the patient
continues to exhibit profound dysmotility and multiple
obstructive complaints. Esophageal extirpation has been
described as a last resort for end-stage achalasia, and this
patient may be a candidate for such aggressive measures
[11].
All patients during an extended follow-up period report
excellent control of symptoms after laparoscopic Heller
myotomy. Frequency of dysphagia still is scored relatively
high, but it is significantly improved from preoperative
levels. Although we now routinely add a concomitant
anterior fundoplication after completing the laparoscopic
Heller myotomy, the majority of individuals do not have
any sort of antireflux operation. Scores for symptoms of
heartburn during long-term postoperative follow-up
assessment are not noted to be particularly higher than
other symptom scores. Patients with ongoing underlying
esophageal dysmotility may have a ‘‘burned out’’ esopha-
gus, and symptoms of reflux can be unreliable.
Objective parameters of gastroesophageal reflux were
not measured long term. Despite the lack of symptoms
123

related to reflux in these patients, there is significant evi-
dence from other groups that the routine addition of a
partial fundoplication confers more benefits than risk [10,
12].
Laparoscopic Heller myotomy can be undertaken with
few complications. This procedure significantly decreases
the frequency and severity of achalasia symptoms without
promoting heartburn symptoms. Symptoms of achalasia are
durably ameliorated by laparoscopic Heller myotomy with
long-term follow-up evaluation, thereby promoting appli-
cation of this procedure.
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