Laparoscopic Heller myotomy in sigmoid megaesophagus: function preserving surgery as an alternative to esophagectomy in end stage achalasia

Abstract

End-stage achalasia with sigmoid megaesophagus represents a therapeutic challenge. Esophageal resection has traditionally been favored, although it is associated with significant morbidity. Laparoscopic Heller myotomy has emerged as a function-preserving alternative in selected patients; however, its use in cases with severe respiratory symptoms and moderate esophageal angulation has not been widely documented. Herein, we report the case of a 43-year-old male with progressive dysphagia, regurgitation, unintentional weight loss, and severe respiratory symptoms (dyspnea and orthopnea). The preoperative Eckardt score was 10 (severe achalasia). Imaging studies demonstrated sigmoid megaesophagus (grade IV) with an esophageal angulation of 75°. Laparoscopic Heller myotomy with intraoperative endoscopy was performed, and 300 mL of retained food content was aspirated. The patient had a favorable postoperative course, with immediate symptom resolution and an Eckardt score of 1 at two months. The hiatal release with anchoring technique (pull down) was not required due to the manageable angulation. Laparoscopic Heller myotomy is an effective option for the management of selected patients with end-stage achalasia and sigmoid megaesophagus, even in the presence of severe respiratory symptoms and moderate esophageal angulation. Appropriate patient selection and meticulous surgical technique allow esophageal preservation with low morbidity and excellent clinical outcomes.