The esophageal pull-down technique improves the outcome of laparoscopic Heller-Dor myotomy in end-stage achalasia

Treatment of end-stage achalasia patients with a sigmoid-shaped esophagus is particularly challenging. A modified technique (pull-down) has been developed to straighten the esophageal axis, but only a limited number of studies on this topic are available in the literature. This study aimed to compare the outcome of patients who underwent the pull-down technique (PDLHD) with that of patients who had a classical Heller-Dor (CLHD). All the patients with a radiological diagnosis of end-stage achalasia who underwent a laparoscopic myotomy (LHD) between 1995-2022 were considered eligible for the study. All of the patients underwent symptom score, barium-swallow, endoscopy and manometry tests before and after the procedure was carried out. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment. Of the 94 patients who were diagnosed with end-stage achalasia (M:F = 52:42), 60 were treated with CLHD and 34 with PDLHD. Two patients (2.1%), both belonging to the CLHD group, developed a squamous cell carcinoma (SCC) during the follow-up. The overall success of LHD was seen in 76/92 patients (82.6%). All the patients in both groups achieved a lower Eckardt score after surgery; there was a failure rate of 27.6% (16/58) in the CLHD group, as compared to 5.9% (2/34) of the PDLHD (p<0.01). The findings of our study confirm that LHD is an effective treatment for end- stage achalasia patients, and the pull-down technique further improves the outcome in these patients so difficult to treat.