Clinical outcome of laparoscopic Heller Cardiomyotomy for achalasia cardia using the Eckardt score: A single-center retrospective study over 10 years

Technical Summary: Clinical Outcome of Laparoscopic Heller Cardiomyotomy for Achalasia Cardia

Problem Statement
Achalasia is a chronic esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent or abnormal peristalsis, leading to dysphagia, regurgitation, chest pain, and weight loss. While Laparoscopic Heller Myotomy (LHM) is an established definitive treatment, there is a scarcity of long-term outcome data from resource-limited settings. Specifically, standardized, symptom-based longitudinal data utilizing the Eckardt score are limited in regions such as Nepal. This study addresses the gap by evaluating the symptomatic outcomes, postoperative complications, and durability of symptom relief following LHM at a tertiary referral center in Nepal over a 10-year period.

Methodology

• Study Design: A single-center, retrospective observational study conducted at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal.
• Population: The study included 48 adult patients (≥18 years) diagnosed with achalasia cardia who underwent Heller cardiomyotomy. Patients with secondary achalasia, prior esophageal/gastric surgery, or incomplete records were excluded.
• Intervention: All patients underwent LHM with a partial Dor fundoplication. The myotomy extended 6–8 cm proximally on the esophagus and 2–3 cm onto the gastric cardia.
• Data Collection: Demographic, clinical, manometric, operative, and follow-up data were extracted from hospital records.
• Primary Outcome Measure: Symptom severity was assessed using the Eckardt score (a composite of dysphagia, regurgitation, chest pain, and weight loss, scored 0–3 per domain, max 12).
  • Clinical Success: Predefined as a postoperative Eckardt score ≤ 3.
  • Statistical Analysis: Preoperative and postoperative scores were compared using the Wilcoxon signed-rank test. Clinical success rates were reported with 95% confidence intervals.
• Follow-up: Duration ranged from 6 to 66 months (mean 36.35 ± 16.40 months).

Key Results

• Demographics: The cohort had a mean age of 36.83 ± 12.27 years with an equal sex distribution (50% male, 50% female). The mean duration of symptoms prior to surgery was 123.5 ± 70.0 months.
• Manometric Subtypes: Manometric classification was available for 31 patients (64.6%). Type II was the predominant subtype (71.0% of classified cases), followed by Type I (22.6%) and Type III (6.5%).
• Symptomatic Improvement:
  • Preoperative Mean Score: 9.50 ± 1.13.
  • Postoperative Mean Score: 1.50 ± 1.13.
  • Reduction: A mean reduction of 8.00 points, representing an 84.2% decrease.
  • Statistical Significance: The reduction was statistically significant (Wilcoxon signed-rank test, P < 0.001).
• Clinical Success: 100% of patients (48/48) achieved a postoperative Eckardt score ≤ 3 (95% CI: 92.6%–100%).
• Complications: The overall complication rate was 6.25% (3/48). All three complications were documented intraoperative mucosal perforations. The remaining 93.75% of patients had no recorded complications.
• Operative Metrics: The mean operative time was 173.5 ± 14.0 minutes. Laparoscopic approach was used in 97.9% of cases.

Significance and Claims
The paper claims that LHM is an effective surgical treatment for achalasia in the specific setting of a tertiary center in Nepal, demonstrating substantial and sustained symptomatic improvement. The study highlights a 100% clinical success rate based on the Eckardt score ≤ 3 criterion within this cohort, alongside a relatively low documented complication rate.

The authors emphasize that the study provides valuable real-world data from a resource-limited setting, supporting the feasibility and efficacy of LHM with Dor fundoplication in this population. They note that the long-term follow-up (up to 66 months in the dataset, with some patients followed for over two decades in the discussion context, though the results section specifies a max of 66 months) suggests durable symptom relief.

Limitations and Modesty of Claims
The authors explicitly acknowledge several limitations that temper the interpretation of their findings:

1. Lack of Variance: A critical methodological observation is that the change in Eckardt score was identical (an 8-point reduction) across all 48 patients. Consequently, the outcome variable had zero variance, making it impossible to statistically analyze associations between patient characteristics (e.g., age, subtype, operative time) and treatment response.
2. Retrospective Nature: The single-center, retrospective design introduces potential selection and follow-up biases.
3. Data Gaps: Manometric classification was missing for 35.4% of patients, and the study lacked objective physiological measures (e.g., timed barium esophagram, repeat manometry) or systematic assessment of gastroesophageal reflux and quality of life.
4. Generalizability: The authors caution that the 100% success rate should be viewed as an observation within this selected cohort rather than evidence of universal permanent symptom resolution. They note that larger, prospective studies with objective measures are required to further define the durability of the procedure.

In conclusion, the paper supports LHM as a viable treatment option in this setting but calls for larger prospective studies incorporating standardized longitudinal follow-up and objective assessments to fully characterize long-term outcomes and predictors of response.