The Evolving Role of Heller-Dor in the Poem Era

Objectives: Peroral endoscopic myotomy (POEM) has emerged as an alternative to laparoscopic Heller myotomy (LHM), but concerns remain regarding postoperative reflux and outcomes in advanced megaesophagus. We evaluated the effectiveness and safety of an extended LHM combined with a modified Dor fundoplication in a contemporary cohort of patients with achalasia. Methods: This retrospective series included 72 consecutive patients with idiopathic or Chagas-related achalasia treated at a university hospital and a private clinic between January 2017 and February 2025. All underwent extended esophageal myotomy (6cm above and 3cm below the esophagogastric junction) with a two-row modified Dor fundoplication. Diagnosis was based on clinical, endoscopic, radiologic, and manometric criteria. Symptom severity was assessed using pre- and postoperative Eckardt scores; scores >3 were considered treatment failure. Megaesophagus grade was determined radiologically according to the Chicago Classification and correlated with outcomes. Patients were followed clinically and endoscopically for up to 45 months. Results: Dysphagia (79%), weight loss (58.3%), and regurgitation (56.9%) were the most frequent preoperative symptoms. The mean preoperative Eckardt score was 5.98, decreasing to 0.52 postoperatively. Occasional residual symptoms were reported by 13 patients (17.33%), but only one (1.4%) met criteria for therapeutic failure, yielding a success rate of 98.6%. There was no mortality. One patient developed atrial fibrillation on postoperative day 1, successfully treated with anticoagulation. No reinterventions were required, and no patient reported symptoms of gastroesophageal reflux during follow-up. Megaesophagus grade, including advanced (III–IV) disease, was not associated with outcome. Conclusions: Extended laparoscopic Heller myotomy with modified Dor fundoplication is a safe and highly effective procedure for achalasia across all degrees of megaesophagus, with excellent symptom control, minimal morbidity, and an apparent protective effect against postoperative reflux. These findings support the continued central role of Heller–Dor in the surgical management of achalasia in the POEM era.