Jarrin Lopez Alberto, Susai Cynthia, Svahn Jonathan D
Department of Surgery, University of California San Francisco East Bay, Oakland, California, USA.
Department of Surgery, Kaiser Permanente-Oakland Medical Center, Oakland, California, USA.
World J Surg. 2025 Sep;49(9):2374-2379. doi: 10.1002/wjs.12695. Epub 2025 Jul 3.
Minimally invasive Heller myotomy (MI-HM) with partial fundoplication is a popular treatment for achalasia. Recent advancements in minimally invasive techniques and enhanced recovery after surgery (ERAS) protocols have facilitated same-day discharge (SDD) for various procedures, promoting cost savings and enhanced patient satisfaction. However, limited data exist on the feasibility and safety of performing MI-HM as an ambulatory operation. This study aimed to evaluate the discharge rate occurring on the same day as surgery, postoperative complications, and reasons for delayed discharge in a single-surgeon cohort of MI-HM patients.
A retrospective review was conducted of 157 consecutive MI-HM cases performed by a single surgeon from 2018 to 2024 at an integrated healthcare system. All patients were evaluated preoperatively with high-resolution manometry, endoscopy, and esophagram. Procedures were performed laparoscopically (n = 35) or robotically (n = 122), with all patients receiving Dor fundoplication. SDD was defined as discharge on postoperative day 0. Primary endpoints included SDD rates and reasons for delayed discharge. Secondary endpoints were 30-day emergency department (ED) visits and postoperative complication rates. Data were analyzed descriptively and stratified into quartiles to assess temporal trends in SDD success.
Of the 157 patients, 132 (84.1%) were discharged on postoperative day 0, with SDD rates improving from 58% in the first quartile to over 90% in subsequent quartiles. Delayed discharge occurred in 25 patients due to patient preference (36%), surgeon discretion (20%), or emesis/aspiration (20%). The overall complication rate was 2.6%, including three aspiration events and one contained leak (0.6%). No reinterventions or mortalities occurred. Out of the 157 patients, 16 patients (10.2%) presented to the ED within 30 days, and from those 16, 13 (8.28%) had surgically related complaints. From the 132 ambulatory patients, 4 (3.03%) presented within 48 h of discharge. Overall reasons for ED presentation were pain, urinary issues, and a contained leak, which was treated conservatively with antibiotics.
This study demonstrates that MI-HM is safe, feasible, and associated with low complication and readmission rates when approached as an ambulatory procedure. Improvements in SDD rates over time reflect enhanced team familiarity and protocol optimization. Given the unique physiological and functional benefits of MI-HM with Dor fundoplication, these findings support its continued use as a treatment for achalasia, with the ambulatory model potentially offering significant cost and resource management benefits. Further studies are warranted to evaluate the generalizability of these findings across diverse healthcare settings.
