457. WHEN LAPAROSCOPIC MYOTOMY FAILS, COMPLEMENTARY PNEUMATIC DILATIONS REPRESENT AN EFFECTIVE AND SAFE OPTION

Abstract

Abstract Background In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia (EA), solving symptoms in most patients. Little is known about the fate of patients who relapsed after LHM, or about their most appropriate treatment. In this study we aimed at evaluating the results of complementary pneumatic dilations (CPD) after ineffective LHM. Methods We evaluated the patients with EA who underwent LHM plus Dor fundoplication (LHD) from 1992 to 2021 and were submitted to CPD for persistent or recurrent symptoms. The patients were followed clinically and with manometry, barium swallow and endoscopy when necessary. An Eckardt score (ES) > 3 was used as threshold for failure both after LHD and after LHD + CPD. Results Out of 1420 patients undergoing LHD in the study period, 115 (8.1%) were considered failures and were offered CPD. Ten patients refused further treatment, in 5 CPD was not indicated for severe reflux esophagitis, 1 patient had surgery for a misshaped fundoplication and 1 last patient developed a cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPD (IQR:1–3), at a median of 16 (IQR:8–36) months after surgery, with 3.0 to 4.0 cm Rigiflex dilator. No perforations were recorded. Only 6 patients were lost to follow up. The remaining 97 were followed for a median of 37 months (IQR:6–112) after the last CPD: 70 saw their symptoms healed, whereas 27 still complained of symptoms (ES > 3). The only differences between the 2 groups were the ES before CPD, that was 3 (IQR:3–4) in the former and 4 (IQR:4–5) in the latter (p < 0.05), and the number of required CPD, that was 2 (IQR:1–2) and 3 (IQR:1–3), respectively (p < 0.05). All other parameters were similar between the 2 groups. Of the un-responding patients, 17 still require repeated CPD, 7 underwent re-myotomy, 1 POEM and 1 esophagectomy for end-stage disease. Conclusion CPD represent an effective and safe option to treat patients after a failed LHD: when the post-surgery ES consistently remains high, and the number of CPD exceeds 3, this may suggest the need for further invasive treatments.