Mucosal injury during laparoscopic Heller cardiomyotomy: risk factors and impact on surgical outcomes

Purpose To investigate the risk factors and outcomes of mucosal perforation (MP) during laparoscopic Heller myotomy (LHM) in patients with achalasia. Methods We conducted a retrospective analysis of patients who underwent LHM for achalasia at a single facility. Results Among 412 patients who underwent LHM for achalasia, MP was identified in 52 (12.6%). Old age, long disease duration, low albumin level, an esophageal transverse diameter > 6 cm, and a sigmoid-shaped esophagus were found to be independent predictors of MP. These factors were assigned a pre-operative score to predict the perforation risk. MP had a significant impact on intra and post-operative outcomes. Gastric side perforation was associated with a higher incidence of reflux symptoms, whereas esophageal-side perforation had a higher incidence of residual dysphagia. Conclusions Many risk factors for MP have been identified. Correctable parameters like low serum albumin should be resolved prior to surgery, while uncorrectable parameters like old age and a sigmoid-shaped esophagus should be managed by experienced surgeons in high-volume centers. Implementing these recommendations will help decrease the incidence and consequences of this serious complication.