# Limited hiatal dissection versus Dor-fundoplication in laparoscopic Heller myotomy for achalasia: First experience in Morocco - A case control comparison study

## TL;DR

The study compares two surgical techniques for treating achalasia and finds that limited hiatal dissection is as effective as Dor fundoplication in relieving symptoms and preventing reflux.

## Contribution

This is the first Moroccan experience comparing limited hiatal dissection and Dor fundoplication in laparoscopic Heller myotomy for achalasia.

## Key findings

- Limited hiatal dissection had shorter operative time and comparable symptom relief compared to Dor fundoplication.
- Both techniques showed similar postoperative reflux rates and dysphagia improvement.
- Limited hiatal dissection is a viable alternative to routine antireflux procedures in achalasia treatment.

## Abstract

Laparoscopic Heller myotomy is a primary treatment for achalasia, addressing impaired esophageal motility. Fundoplication is typically added to prevent postoperative reflux. This study compares outcomes of limited hiatal dissection without antireflux system in laparoscopic Heller myotomy to Dor fundoplication.

A retrospective analysis was conducted on 45 patients treated at visceral surgery department (2008–2022). Of these, 29 patients underwent limited hiatal dissection, and 16 underwent Dor fundoplication. A liquid diet was followed on day one, with discharge on day two, and a semi-liquid diet for three weeks. Outcomes included dysphagia resolution, postoperative Eckardt scores <3, and postoperative reflux incidence. The study compared operative and postoperative data between the two groups.

The limited hiatal dissection group had a slightly younger mean age (46.97 years) compared to the Dor fundoplication group (51.75 years). The limited hiatal dissection group had a higher proportion of men (58.6 %) while the Dor group had more women (56.3 %). Dysphagia (100 %) and weight loss (68.9 %) were prevalent symptoms. Perioperative complications and hospital stay duration were similar. Operative time was significantly shorter in the limited hiatal dissection group (96.7 vs. 118.3 min, p = 0.004). Both groups showed similar (OR = 0.519, CI = 0.066–4.083) and significant improvement in dysphagia (91.3 % vs. 87.5 %, p < 0.001) with comparable postoperative gastroesophageal disease (20.7 % vs. 25 %, p = 0.726 OR = 1.278, 95 % CI: 0.301–5.420).

Limited hiatal dissection provides comparable symptom relief and reflux prevention, offering a viable alternative to routine antireflux in achalasia treatment.

•Laparoscopic Heller Myotomy provides dysphagia relief in 70% and 90% of achalasia cases.•Postoperative challenges, including persistent dysphagia and gastroesophageal reflux disease, remain significant concerns.•Partial fundoplication is effective in reducing gastroesophageal disease but may add complexity and risk persistent dysphagia.•Limited hiatal dissection approach preserves the physiological anti-reflux system while minimizing complications and reduce operative duration.•In light of our study, limited hiatal dissection proves to be an equivalent approach to Dor fundoplication, offering comparable efficacy in the alleviation of symptoms and postoperative reflux prevention.

Laparoscopic Heller Myotomy provides dysphagia relief in 70% and 90% of achalasia cases.

Postoperative challenges, including persistent dysphagia and gastroesophageal reflux disease, remain significant concerns.

Partial fundoplication is effective in reducing gastroesophageal disease but may add complexity and risk persistent dysphagia.

Limited hiatal dissection approach preserves the physiological anti-reflux system while minimizing complications and reduce operative duration.

In light of our study, limited hiatal dissection proves to be an equivalent approach to Dor fundoplication, offering comparable efficacy in the alleviation of symptoms and postoperative reflux prevention.