Comparative Analysis of Heller–Gottstein Myotomy Outcomes before and after Implementation of a Technique for Straightening the Vertical Axis of the Esophagus in Stage IV (Sigmoid) Cardia Achalasia

Introduction. Stage IV (sigmoid) cardia achalasia (CA) is characterized by marked esophageal dilation and S-shaped deformity, leading to severe impairment of bolus transit and significant deterioration in quality of life. In end-stage disease, conventional Heller–Gottstein myotomy often fails to restore adequate esophageal emptying, and esophagectomy is frequently considered despite its substantial morbidity. In recent years, interest has grown in organ-preserving procedures that include correction of axial esophageal deformity. Aim: this study aimed to compare outcomes of the Heller–Gottstein procedure in patients with stage IV CA using the classical technique versus a modified approach incorporating straightening of the vertical esophageal axis.

Materials and methods. A comparative analysis was performed in 63 patients with stage IV CA who underwent surgery before and after adoption of the modified technique. Group I included patients treated between 1982 and 2007 with classical Heller–Gottstein myotomy. Group II included patients operated on between 2008 and 2024 using the modified approach with vertical axis correction. Treatment efficacy was assessed in the early postoperative period and at 24 months using clinical evaluation, endoscopy, radiography, the Eckardt score, and the Gastrointestinal Quality of Life Index (GIQLI).

Results. The groups were comparable preoperatively across key baseline characteristics (p > 0.05). Persistent dysphagia resolved in all patients in the early postoperative period. However, S-shaped deformity persisted in 100% of Group I and in 21.4% of Group II (p < 0.001). At 24 months, Group II demonstrated significantly lower symptom severity according to the Eckardt score (2 [0–2.25] vs 3 [1–4], p = 0.044), a markedly lower rate of persistent sigmoid deformity (5% vs 71.4%, p < 0.001), and higher GIQLI scores (133 vs 114 points, p = 0.001).

Discussion. Correction of the vertical esophageal axis appears to be a key determinant of improved long-term functional outcomes in stage IV CA. Conclusion. The incorporation of vertical axis straightening into the Heller–Gottstein myotomy significantly improves long-term functional results in patients with stage IV cardia achalasia.

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