Doing more with less: our decade of experience with laparo-endoscopic single site Heller myotomy supports its application

Background: Achalasia is a rare esophageal motility disorder that affects 1 in 100,000 individuals. Currently, laparoscopic Heller myotomy with anterior fundoplication is the 'gold standard' therapy for achalasia, alleviating symptoms by de-functionalizing the lower esophageal sphincter mechanism. The advent of the Laparo-Endoscopic Single Site (LESS) technique provides a more minimally invasive approach to Heller myotomy.

Methods: With IRB approval, 179 patients who underwent LESS Heller myotomy with anterior fundoplication since 2007 have been prospectively followed. Patients self-assessed symptom frequency and severity preoperatively and postoperatively using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Patients scored their scar satisfaction (1 = revolting to 10 = beautiful). Data are presented as median (mean ± SD). Significance was accepted with 95% probability.

Results: Fifty-one percent of patients were men, of age 55 (53 ± 17) years and BMI of 25 (25 ± 6.1) kg/m². Patients had an operative time of 134 (135 ± 34.3) minutes with an estimated blood loss (EBL) of 50 mL. Postoperative complications occurred in 18% of patients (e.g., urinary retention, capnothorax). Length of stay was 1 (2 ± 2.1) day. Preoperatively, symptoms (e.g., dysphagia, regurgitation) were frequent and severe; following myotomy, all symptoms queried were significantly less frequent and severe with follow-up of 28 (34 ± 18.4) months (p < 0.0001 for all, paired Student's t test). Eighty-seven percent of patients reported they were 'very satisfied' or 'satisfied' with their experience and 95% of patients would undergo the operation again knowing what they know now. Patients scored their satisfaction with their scar as 10 (9 ± 1.6).

Conclusion: Heller myotomy with anterior fundoplication undertaken via the LESS approach provides efficacious, satisfactory, and durable amelioration of symptoms. Patients reported significant symptom resolution as well as satisfaction with their overall experience. Our decade of experience documenting the salutary benefits of LESS Heller myotomy should be more than enough to encourage surgeons to incorporate the approach into their armamentarium.