Esophagus-preserving surgery vs. esophagectomy for advanced achalasia: a narrative review

Introduction

Achalasia is a rare esophageal motility disorder that may evolve into advanced megaesophagus with severe dilation, malnutrition, and aspiration risk. Esophagectomy has long been considered the standard operation for end-stage disease but carries substantial morbidity and mortality.

Despite historical use of esophagectomy, several esophagus-preserving techniques have been proposed to reduce operative trauma and maintain continuity. However, few studies directly compare these alternatives or standardize outcome reporting, leaving uncertainty about their relative efficacy and indications.

This review aims to summarize and critically analyze surgical strategies that preserve the esophagus in advanced achalasia and megaesophagus, comparing their technical diversity, outcomes, and clinical applicability. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-26/rc).

Methods

Search strategy and study selection

A narrative literature review was conducted with electronic searches performed between June and August 2025 (Table 1). The following databases were searched: PubMed/MEDLINE, Embase, Scopus, and SciELO. The search was performed between June and August 2025; studies published between 2000 and 2025 were considered. MeSH and free-text terms included: achalasia, megaesophagus, end-stage achalasia, sigmoid megaesophagus, esophagectomy, Heller myotomy, extended myotomy, esophageal mucosectomy, Serra Doria, Thal, Thal-Hatafuku, cardioplasty, and related surgical descriptors. These terms were combined using Boolean operators (AND, OR). Reference lists of key publications were also hand-searched for additional relevant studies.

Inclusion and exclusion criteria

Original articles, review articles, case series, and clinical guidelines published in English, Spanish, or Portuguese describing esophagectomy and surgical alternatives to esophagectomy for advanced achalasia or megaesophagus were included. Isolated case reports, studies focused solely on endoscopic procedures [e.g., peroral endoscopic myotomy (POEM), pneumatic dilation, botulinum toxin], and articles without full-text availability or lacking relevant clinical or technical data were excluded.

Study selection and data extraction

Two reviewers independently screened titles and abstracts, followed by a full-text review of potentially eligible studies. Discrepancies were resolved by consensus. Data extracted included: study design, patient population, surgical technique, perioperative and long-term outcomes, symptom relief, complications, and follow-up duration. Given the narrative design, methodological quality was qualitatively appraised. Study design (retrospective vs. prospective, single-center vs. multicenter), sample size, and follow-up duration were considered to contextualize the level of evidence. This study follows a narrative review framework; therefore, data synthesis is descriptive rather than quantitative meta-analysis. A summary of the included studies is presented in Table 2.

Results

Esophagectomy

Over the years, various attempts have been made to classify or define end-stage achalasia, most of which have been based on radiological criteria. In 2018, the International Society for Diseases of the Esophagus (ISDE) (1) published a consensus recommending the barium esophagram as the reference examination to characterize advanced disease. The most characteristic finding is the marked dilation associated with tortuosity of the esophagus, known as the “sigmoid” esophagus. The accumulation of contrast in the distal segment, called the “sump”, and the difficulty of esophageal emptying are conditions that increase the risk of aspiration and limit the effectiveness of myotomy in advanced cases. In these cases, esophagectomies are widely indicated, mainly by the transhiatal or three-field approach (abdominal, thoracic, and cervical), which can be performed conventionally, laparoscopically, or robotically.

Several studies have demonstrated that esophagectomy constitutes a viable therapeutic option for patients with advanced achalasia, especially in those refractory to previous procedures. Although considered safe when performed by experienced surgeons, the technique poses additional technical challenges in these cases due to esophageal axis deformity and adhesions from prior treatments. The most frequently reported complications include cervical anastomotic fistula in about 10%, generally managed conservatively, as well as mediastinal bleeding, chylothorax (due to iatrogenic injury to the azygos vein), recurrent laryngeal nerve injury, abscesses, and, in isolated cases, tracheal perforation. The overall morbidity ranged from 30% to 60% across the analyzed studies, with low mortality (3% to 5%), consistent with other published series and reinforcing the safety of the procedure when judiciously indicated. From a functional point of view, the majority of patients showed a satisfactory evolution, with regression of dysphagia, significant weight gain in the first postoperative year, and improved quality of life. However, persistent symptoms such as mild nocturnal regurgitation, post-vagotomy diarrhea, and dumping symptoms were described in up to 40% of cases. Regarding esophageal substitutes, the stomach was preferred due to its good vascularization and the need for only one anastomosis, although colonic interposition is an alternative in selected situations.

Esophagectomy can offer lasting symptomatic relief and good eating function in advanced achalasia. Still, it is a procedure with high morbidity and a non-negligible risk of mortality, especially in highly dilated and deviated esophagi with adhesions from previous treatments. Therefore, it should be indicated sparingly, ideally in experienced centers, after the exhaustion of less invasive alternatives and after clinical/nutritional optimization, and always through shared decision-making, individual risk assessment, and technical planning to reduce complications.

Heller myotomy

Throughout the 1990s, achalasia surgery evolved from endoscopic dilation and open myotomy to the laparoscopic approach, a less invasive method. Current evidence suggests that the inclusion of a partial fundoplication in laparoscopic Heller myotomy significantly reduces reflux without impairing the passage of food through the esophagus. This article is based on the analysis of several studies in the literature, with a special emphasis on three that represent different approaches and contexts. The first, a retrospective study from Salvador et al. (2) followed 164 patients with sigmoid or dilated esophagus who underwent laparoscopic Heller myotomy with Dor fundoplication. The second is a systematic review and meta-analysis from Chaib et al. (3) that compared laparoscopic cardiomyotomy with major surgeries for advanced megaesophagus.

In the first study, the results showed that the sigmoid esophagus (SE) group had a significantly longer symptom duration (60 months) and lower esophageal pressures than the non-sigmoid esophagus (NSE) group. The surgery was completed laparoscopically in all cases, with rare esophageal perforations (4.3%) without serious consequences. Although the majority of patients (89% in the NSE group and 71.2% in the SE group) had a satisfactory outcome, the surgical success rate was lower in the SE group, particularly among patients with a history of endoscopic treatments. However, the combination of surgery and additional treatments, such as endoscopic dilation, achieved an overall success rate of 83.5% in the SE group. The rate of postoperative acid reflux was similar in both groups. In the second study, the results showed that both approaches presented predominantly good or excellent late outcomes. However, cardiomyotomy stood out for having a significantly lower morbidity and mortality rate. While major surgeries had a relative risk of complications and mortality of 0.49 and 0.05, respectively, cardiomyotomy had a risk of 0.08 and 0.03. In the third study, the results showed that swallowing success, evaluated at the most recent follow-up, was high and similar across all groups (90% overall), regardless of esophageal diameter or shape. However, there was a statistically significant trend toward a greater risk of persistent or recurrent dysphagia in patients with an esophageal diameter greater than 6 cm. Thus, laparoscopic Heller myotomy with partial fundoplication is established as a safe and highly effective surgical treatment for achalasia, including those with SE and Chagas megaesophagus, offering low rates of complications and mortality. Although patients with more dilated esophagi may be at a greater risk of recurrent dysphagia, the surgical approach combined with endoscopic dilation, when necessary, achieves high success rates. Therefore, it should be considered first-line therapy, with more invasive procedures reserved for specific cases of surgical failure or for patients with other indications, such as the presence of associated dysplasia.

Laparoscopic Heller-Dor (LHD) with pull-down technique

Recently, the LHD + pull-down modification has been introduced to straighten the esophageal axis in sigmoid or end-stage achalasia. First described by Faccani et al. (4) (2007, Eur J Cardiothorac Surg) and supported by Herbella et al. (5) (SSAT Global Outreach 2025) and Nezi et al. (6) (2024, J Gastrointest Surg), this approach combines extended myotomy, Dor fundoplication, and gentle caudal mobilization of the distal esophagus into the abdomen. These studies demonstrated >80% symptom relief and reduced the need for esophagectomy in 4 of 5 patients with end-stage achalasia. The technique is reproducible, laparoscopic, and should be considered before esophagectomy.

Cardioplasty and Roux-en-Y partial gastrectomy: Serra Doria procedure

As described by Ponciano et al. (7), referring to the procedure originally proposed by Holt et al. and later disseminated in South America by Serra Doria, consists of combining Gröndahl’s cardioplasty (a side-to-side esophagogastroplasty), truncal vagotomy, and Roux-en-Y partial gastrectomy (Figure 1). This technique, known as the Serra Doria operation, was conceived as an alternative to esophagectomy in patients with advanced megaesophagus or recurrence after myotomy, with the aim of preserving the esophagus and reducing postoperative complications. Among the reported benefits are the maintenance of esophagogastric junction patency, prevention of both acid and alkaline reflux, and lower morbidity and mortality compared with esophagectomy. Moreover, the procedure can also be applied to patients with a history of prior gastric surgery. In Brazilian literature, Ponciano et al. (7) evaluated 20 patients who underwent this technique and observed significant clinical improvement, with dysphagia relief in 88% of cases after an average follow-up of nearly 2 years. Although complications such as dumping syndrome and anemia occurred in some patients, all showed a reduction of esophageal caliber, reinforcing the efficacy of the surgery in disease control. In a retrospective study, Stefani-Nakano et al. (8) compared the Serra Doria operation with esophagectomy in patients with recurrent or advanced megaesophagus. After a median follow-up of more than 6 years, both procedures demonstrated similar outcomes in terms of quality of life and nutritional status.

Figure 1 Serra-Doria operation combining Gröndahl’s cardioplasty with Roux-en-Y gastric reconstruction. Source: Author’s personal collection, 2025.

Thal surgery

In 1965, Thal (9) described a surgical alternative for treating distal esophageal perforations by suturing the gastric fundus to the compromised esophageal segment. Experimental studies demonstrated that, after several weeks, esophageal epithelium was able to cover the gastric serosa at the perforation site. Hatafuku (9) proposed a modification of this method by creating an antireflux valve through invagination of the gastric fundus mucosa into the esophageal lumen. Thus, during gastric distension, the invaginated mucosa acted as a barrier against reflux. Initially performed through a thoracic approach, the technique was later performed preferentially via laparotomy, becoming known as the Thal-Hatafuku operation, and was used in the management of chagasic megaesophagus. The surgical procedure essentially consisted of a longitudinal esophageal incision a few centimeters above and below the esophagogastric junction, followed by the creation of a mucosal “rosette” and subsequent coverage of the esophageal defect with the gastric fundus. Immediate results observed with the procedure included radiologic regression of esophageal dilatation and early clinical improvement of symptoms. In long-term follow-up, however, some patients developed gastroesophageal reflux, identified both clinically (heartburn and retrosternal pain) and through objective tests. Despite this, most patients had a satisfactory evolution. Even recurrent symptoms were manageable with clinical treatment and did not compromise quality of life. These findings, consistent with previous reports, reinforce the safety of the Thal-Hatafuku technique, which is associated with low operative morbidity and mortality and favorable outcomes in more than 90% of treated cases, establishing it as a relevant option in the surgical management of advanced megaesophagus (10).

Esophageal mucosectomy with pullthrough: Aquino operation

In 2000, Aquino (11) described a technique to remove the esophageal mucosa and submucosa while preserving the mediastinal muscular layer, without the need for thoracotomy. The approach was cervicoabdominal, and digestive tract reconstruction was achieved through posterior mediastinal gastroplasty, positioning the stomach within the preserved muscular layer, or alternatively through a retrosternal route. This approach was proposed for patients with advanced megaesophagus, offering a less aggressive option compared with traditional esophagectomy. The procedure included sectioning of vagal branches, longitudinal incision of the muscular layer of the abdominal and cervical esophagus to dissect and isolate the mucosa-submucosa throughout its circumference, and gastric preparation for future transposition. After en bloc mucosectomy, the stomach was guided to the cervical region, either through the posterior mediastinum within the preserved muscular sheath or via the retrosternal route. Esophagogastric anastomosis was preferably performed on the posterior wall of the gastric fundus. Among operated patients, early mortality was 3.3%, related to cardiovascular and pulmonary complications. Respiratory complications occurred in about 5% and were associated with favorable outcomes after clinical treatment or chest drainage. Cervical anastomotic dehiscence was observed in 10% of cases; half evolved well with conservative management, while the others developed strictures that were successfully treated with endoscopic dilatations.

Discussion

Care must be given to the complexity, morbidity, and mortality of esophagectomy. As patients with this condition often present with malnutrition and several comorbidities, esophageal-sparing techniques should be considered in advance to provide long-term resolution of symptoms, quality of life, and patient satisfaction.

Of note, Chagas disease must be highlighted in this context. As several developing countries still face its endemic presence, chagasic megaesophagus plays a major role in two aspects. First, the patient’s clinical and demographic profile, as they are often low-income, elderly, facing long-term weight loss and enduring different conditions (e.g., chagasic cardiomyopathy, arrhythmia, heart failure), with relevant impact in major surgery. Second, the infrastructure and technological support for these patients, who mainly demand public health systems of poor countries, does not provide minimally invasive techniques (laparoscopic or robotic platforms) or advanced endoscopic procedures (POEM) to their full demand. Therefore, alternative surgical solutions remain relevant in this scenario, helping many patients achieve treatment success despite adverse conditions.

Different esophageal-preserving techniques have been described over time. Heller cardiomyotomy is proven effective even in end-stage achalasia, with feasible laparoscopic and robotic approaches, supported by more robust evidence despite most studies being retrospective. Similarly, Thal and Serra Doria procedures are good alternatives to esophagectomy, offering satisfactory results and minimally invasive options, although evidence is limited. Unlike Heller myotomy, which is more reproducible and widely performed via minimally invasive techniques, the Serra Doria procedure presents greater technical difficulties when attempted laparoscopically or robotically and tends to be more costly. Its approach of combining cardiomyotomy with a partial gastrectomy to improve gastric emptying and reflux control involves removing a healthy part of the stomach, raising concerns about long-term functional and nutritional effects. That cardioplasty, although less radical than Serra Doria, is also less standardized than Heller myotomy and has limited supporting evidence for routine use.

Esophageal mucosectomy, as described by Aquino (11), is another esophagus-preserving option for advanced achalasia and megaesophagus. The procedure has demonstrated favorable functional outcomes and acceptable morbidity in selected cases, while maintaining esophageal continuity. However, it is limited in reproducibility and remains restricted to open surgery, with no current minimally invasive adaptation. Moreover, the evidence is mostly from single-center reports and retrospective studies, highlighting the need for higher-quality research before wider adoption can be recommended.

Comparative analysis of esophagus-preserving techniques

Extended Heller-Dor remains the most reproducible and widely applicable approach, particularly in centers with expertise in minimally invasive techniques. Serra Doria offers effective reflux control but requires partial gastrectomy, limiting future use of the stomach as an esophageal substitute. Thal-Hatafuku has historical relevance, with >90% symptom improvement but higher reflux risk. Esophageal mucosectomy (Aquino) preserves continuity but is limited to open surgery. The LHD + pull-down technique combines minimally invasive access with functional axis correction, avoiding esophagectomy in most advanced cases. Selection should consider patient comorbidity, nutritional status, and local resources.

In patients with prior failed endoscopic or surgical treatment, the choice of procedure must anticipate possible future reconstruction needs. For example, Serra Doria’s partial gastrectomy precludes gastric conduit use in subsequent esophagectomy, whereas Heller-Dor and pull-down approaches preserve this option.

Strengths and limitations

This review integrates surgical experience across idiopathic and chagasic achalasia, highlighting rare procedures seldom compared in modern literature. However, most included studies are retrospective and single-center, limiting generalizability. The lack of quantitative synthesis and publication bias are inherent limitations to narrative reviews.

Conclusions

Management of advanced achalasia demands balance between symptom control and surgical risk. Esophagus-preserving techniques—particularly extended laparoscopic Heller-Dor and the pull-down modification—achieve high functional success with reduced morbidity compared to esophagectomy. Serra Doria and Thal-Hatafuku remain valuable in selected settings, while mucosectomy offers continuity in extreme cases.

Extended Heller-Dor with pull-down should be prioritized as first-line therapy before esophagectomy.

Future multicenter and registry-based studies comparing long-term functional and nutritional outcomes are essential to refine patient selection and optimize surgical strategy.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-26/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-26/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-26/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Zaninotto G, Bennett C, Boeckxstaens G, et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018;
2. Salvador R, Nezi G, Forattini F, et al. Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia. Surg Endosc 2023;37:1742-8. [Crossref] [PubMed]
3. Chaib PS, Tedrus GA, Aquino JLB, et al. Advanced megaesophagus treatment: which technique offers the best results? A systematic review. Arq Bras Cir Dig 2024;37:e1809. [Crossref] [PubMed]
4. Faccani E, Mattioli S, Lugaresi ML, et al. Improving the surgery for sigmoid achalasia: long-term results of a technical detail. Eur J Cardiothorac Surg 2007;32:827-33. [Crossref] [PubMed]
5. Herbella FAM, Shada AL, da Rocha JRM, et al. Expert opinion on the management of esophageal achalasia from the Society for Surgery of the Alimentary Tract (SSAT) Global Outreach Committee. Ann Esophagus 2025;8:13.
6. Nezi G, Forattini F, Provenzano L, et al. The esophageal pull-down technique improves the outcome of laparoscopic Heller-Dor myotomy in end-stage achalasia. J Gastrointest Surg 2024; Epub ahead of print. [Crossref]
7. Ponciano H, Cecconello I, Alves L, et al. Cardiaplasty and Roux-en-Y partial gastrectomy (Serra-Dória procedure) for reoperation of achalasia. Arq Gastroenterol 2004;41:155-61. [Crossref] [PubMed]
8. Stefani-Nakano SM, Faintuch J, Rocha JM, et al. Quality of life of patients operated for advanced Chagas’ megaesophagus. ABCD Arq Bras Cir Dig 2005;18:129-32.
9. Thal AP, Hatafuku T, Kurtzman R. New operation for distal esophageal stricture. Arch Surg 1965;90:464-72. [Crossref] [PubMed]
10. Ferraz AA, da Nóbrega Júnior BG, Mathias CA, et al. Late results on the surgical treatment of Chagasic megaesophagus with the Thal-Hatafuku procedure. J Am Coll Surg 2001;193:493-8. [Crossref] [PubMed]
11. Aquino JLB, Neto JAR, Muraro CLPM, et al. Esophageal mucosectomy in the treatment of the advanced megaesophagus: analysis of 60 cases. Revista do Colégio Brasileiro de Cirurgiões 2000;27:108-13.