AB047. SOH25_AB_228. Hybrid Heller’s myotomy: a poetic approach

Background: Laparoscopic Heller myotomy (LHM) for achalasia is associated with mucosal perforation rates of up to 28% in primary procedures and 50% in reoperations, with inadequate myotomy contributing to treatment failure in 33% of patients. This study hypothesized that integrating oesophagogastroduodenoscopy (OGD) during LHM as a hybrid Heller myotomy (HHM) technique could reduce the incidence of mucosal perforation and incomplete myotomy. The study evaluated intraoperative safety, myotomy success, and long-term outcomes of this hybrid approach.

Methods: The HHM technique combined laparoscopic myotomy with simultaneous OGD to assess mucosal integrity and verify complete muscle division in real time. Alternating light sources and luminal insufflation were utilized during critical steps to confirm myotomy completeness. Operative records were reviewed, and long-term symptomatic outcomes were assessed using the Eckardt score at 5 years postoperatively.

Results: Among 35 procedures, no intraoperative mucosal perforations occurred. Long-term follow-up was available for 20 patients, with 15 (75%) achieving an Eckardt score of less than or equal to 3 at 5 years or longer, reflecting durable symptomatic relief up to 16 years postoperatively. Two patients experienced moderate-to-severe symptom recurrence, and one had moderate symptom recurrence.

Conclusions: OGD surveillance during HHM minimizes the risk of mucosal perforation and incomplete myotomy, and we propose this approach, especially for high-risk patients, such as those undergoing redo-Heller myotomy or reoperation following per-oral endoscopic myotomy (POEM). HHM ensures precise myotomy, minimises mucosal injury risk and facilitates effective fundoplication, ensuring sustained symptomatic relief in the majority of patients.

Keywords: Achalasia; esophagogastroduodenoscopy; esophageal perforation; laparoscopic heller myotomy (LHM); per-oral endoscopic myotomy (POEM)