Objective To investigate the influencing factors for gastroesophageal reflux disease (GERD) after laparoscopic Heller‑Dor surgery for esophageal achalasia.
Methods The retrospective case‑control study was conducted. The clinical data of 210 patients with esophageal achalasia who were admitted to Shanxi Provincial Cancer Hospital from January 2021 to December 2023 were collected. There were 119 males and 91 females, aged (47±12)years. All patients underwent laparoscopic Heller‑Dor surgery. Observation indicators: (1) surgical situations; (2) follow‑up; (3) influencing factors for GERD after laparoscopic Heller-Dor surgery; (4) development and evaluation of a predictive model for GERD after laparoscopic Heller‑Dor surgery. Univariate and multivariate analyses were performed using stepwise Logistic regression. Results of multivariate analysis were used to construct a nomogram in predicting GERD. The predictive performance was assessed using the area under the receiver operating characteristic curve. The calibration curve was used to evaluate the accuracy of the model, and the decision curve was used to assess the overall net benefit of the model.
Results (1) Surgical situations. All 210 patients underwent laparoscopic Heller‑Dor surgery. The operation time was (128±31)minutes, volume of intraoperative blood loss was (25±9)mL, and length of lower esophageal sphincter (LES) myotomy was (5±3)cm. The length of low esophageal myotomy >6 cm was performed in 49 patients, and length of gastric fundus myotomy >2 cm was performed in 58 patients. Intraoperative mucosal perforation occurred to 3 patients and was repaired intraoperatively. One patient required conversion to open surgery. Postoperative complications occurred in 18 patients. The duration of postoperative hospital stay was (4.3±2.4)days. (2) Follow‑up. All 210 patients were followed up for 4(range,7-33)months after surgery. During follow‑up, 32 pati-ents had GERD, including 17 cases presenting dysphagia and 25 cases presenting acid regurgitation and heartburn (the same patient may have two symptoms). There were 29 cases with body mass index (BMI) >28 kg/m². Symptom severity scores of 210 patients showed heartburn of 0.6(range, 0-3.0), reflux of 0.7(range, 0-3.0), chest pain of 0.4(range, 0-2.0), cough and hoarseness of 0.5(range, 0-2.0), nausea and vomiting 0.3(range, 0-2.0), dysphagia 0.8(range, 0-3.0). The LES pressure was (15±8)mmHg (1 mmHg=0.133 kPa), LES relaxation rate was 81%±13.0%, and integrated relaxation pressure was (9±6)mmHg. Esophageal manometry classification showed type Ⅰ, Ⅱ, and Ⅲ in 0, 8, and 0 patients, respectively. There were 208 patients achieved symptom relief after drug or symptomatic treatment. Only two patients with severe symptoms were unresponsive to medication and subsequently underwent surgery at another hospital, with symptoms improving postoperatively. (3) Influen-cing factors for GERD after laparoscopic Heller‑Dor surgery. Results of multivariate analysis showed that male, smoking history, length of lower esophageal myotomy >6 cm, and postoperative BMI >28 kg/m² were independent risk factors for GERD after laparoscopic Heller‑Dor surgery (odds ratio=4.02, 6.34, 5.41, 7.38, 95% confidence interval as 1.50-10.78, 3.31-12.31, 1.77-13.47, 2.80-15.42, P<0.05). (4) Development and evaluation of a predictive model for GERD after laparoscopic Heller‑Dor surgery. A predictive nomogram model for GERD was constructed based on the results of multivariate analysis. The receiver operating characteristic curve of predictive nomogram model for GERD had an area under curve of 0.91 (95% confidence interval as 0.82-0.97), demonstrating good discrimination. The calibration curve showed good agreement between predicted and observed probabilities, with a mean absolute error of 0.033. The decision curve demonstrated that within a threshold probability range of 0.2-0.8, the predictive model had greater net benefit than "treat‑all" or "treat‑none" strategies, indicating clinical utility of this model in clinical decision.
Conclusions Male, smoking history, length of lower esophageal myotomy >6 cm, and postoperative BMI >28 kg/m² are independent risk factors for GERD after laparoscopic Heller‑Dor surgery for esophageal achalasia. The predictive model for GERD after laparoscopic Heller‑Dor surgery based on these factors shows strong predictive accuracy.
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