Abstract
Abstract Background Re-operations after Heller myotomy for esophageal achalasia is a challenging operation due to the fibrotic tissue surrounding the esophago-gastric junction (EGJ). The risk of both undertreatment or, on the other hand, esophageal perforation is significant. The impedance planimetry could guide the operation and assess whether the patients needs further dissection of adhesions, an extension of the previous myotomy and anti-reflux treatment. Methods A 70-year-old woman treated with Heller-Nissen in 1983 for type II achalasia was referred to our tertiary care center with absolute dysphagia for three days. In the past 41 years she reported occasional and self-limited episodes of dysphagia, regurgitation and chest pain. Aside from that, her medical history was unremarkable. An esophagogastroduodenoscopy (EGD) with airway protection was performed, showing retained solid food. A water-soluble swallow study showed a tortuous megaesophagus and a misaligned esophageal gastric junction (EGJ), which did not allow endoscopic dilation. Esophageal wall thickening and focal lesions were ruled out by a CT scan. Results A laparoscopy with impedance planimetry technology support was scheduled. The first EGJ distensibility index (EGJ-DI) measurement was 2.1 mm2/mmHg. Esophagus was freed, encircled and released from the hiatus. An EGD confirmed the reposition of the cardia in the abdomen and the previous anterior esophageal myotomy. The Nissen fundoplication was not detectable. At this stage, an EGJ-DI of 4,2 mm2/mmHg was found. To obtain a regular esophageal outflow an anterior myotomy of the EGJ and proximal stomach was carried out and the edge was everted with absorbable barbed suture. A posterior cruroplasty was then performed. The final EGJ-DI was 8,8 mm2/mmHg. Conclusion The postoperative course was uneventful and she was discharged on post-operative day 4 eating a soft diet. In conclusion, the intraoperative use of the impedance planimetry technology has been crucial for a correct decision-making process during complex redo operations for esophageal achalasia as it has helped to tailor the surgical treatment. https://www.dropbox.com/scl/fi/pednopcqnalooidynge3q/ISDE-Definitivo.mov?rlkey=8exx0oe6ompxoex8wqmlsgi0i&st=xgnfnjyt&dl=0
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