Balancing relief and reflux: A prospective comparative study on gastric myotomy length and post-operative outcomes in laparoscopic Heller’s myotomy for achalasia

Abstract Introduction: Laparoscopic Heller’s myotomy (LHM) with a partial fundoplication is the standard surgical therapy for achalasia cardia. However, the ideal gastric extension of the myotomy remains controversial, as it may influence both symptom relief and post-operative gastro-oesophageal reflux disease (GORD). This study prospectively assessed the impact of gastric myotomy length on clinical outcomes after LHM with Dor fundoplication. Patients and Methods: In this prospective non-randomised comparative interventional study, patients undergoing LHM with Dor fundoplication were divided into three groups according to gastric myotomy length: Group A (<1.5 cm), Group B (1.5–2.5 cm) and Group C (>2.5 cm). The primary outcome was improvement in the Eckardt score at 1, 3 and 6 months postoperatively. The secondary outcomes included GORD incidence (Gastro-Oesophageal Reflux Disease Questionnaire [GORD-Q]), complications and re-intervention rates. Results: Sixty-three patients were included ( n = 21 per group). All groups showed significant symptom improvement post-surgery. At 3 and 6 months, Groups B and C demonstrated greater Eckardt score improvement than Group A ( P = 0.012 and P < 0.01, respectively). Median GORD-Q scores were similar at 1 and 3 months but higher in Group C at 6 months ( P = 0.01). Re-intervention was most frequent in Group A (23.8%) due to persistent dysphagia ( P = 0.047). Operative time, hospital stay and complications did not differ significantly among the groups. Conclusion: Gastric myotomy beyond 1.5 cm improves symptom control after LHM with Dor fundoplication, but extension beyond 2.5 cm increases reflux risk. A length of 1.5–2.5 cm appears optimal for balancing dysphagia relief and reflux prevention.