Return of Peristalsis After Heller Myotomy: A Rare Case

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Achalasia is characterized by esophageal aperistalsis and failure of lower esophageal sphincter (LES) relaxation. Anatomical abnormalities lead to dysphagia, heartburn, regurgitation, epigastric or noncardiac chest pain. We present a case of a patient with achalasia II who had return of peristalsis after Heller myotomy. A 48-year-old female presented with dysphagia, regurgitation and a 40 lbs weight loss in 3 months. Significant past medical history of acid reflux disease, H. Pylori and a 9.5 pack year smoking history. On upper endoscopy (EGD) the gastroesophageal junction was tight and therapeutically dilated. High-resolution esophageal manometry (HRM) confirmed achalasia II with high-integrated relaxation pressure, and panesophageal pressurization. (Image 1) One month later, she underwent Heller myotomy with Dor fundoplication. Over the next 8 months her symptoms recurred requiring 3 dilations. Repeat HRM showed LES relaxation with a high normal IRP. There was esophageal compartmentalized pressurization, esophageal foreshortening and evidence of peristaltic contractions not seen on the prior HRM (Image 2). We believe her recurrent symptoms were due to the fundoplication. HRM increased understanding of achalasia and led to the Chicago Classification currently in version 3.0. Chicago Classification has 3 subgroups with achalasia under the first group. Literature review revealed a handful of patients with return of peristalsis after intervention. Ponce et al.1 and Parrilla et al.2 reported return of peristalsis in patients after Heller's myotomy. The subset of achalasia patients that regain peristalsis after correcting LES obstruction could be explained by three scenarios. First, HRM may inadequately differentiate EGJ outflow obstruction and achalasia. Second, this may be a very early diagnosis of achalasia. Third, this may be a new phenotype that becomes apparent after intervention. Functional lumen imaging probe (FLIP) topography may have an adjunct role for clear classification of phenotypes. Carlson et al.3 reported a 31% variability in achalasia II patients using FLIP topography compared to HRM. Further research and continued monitoring is required to properly diagnose and classify patients with return of peristalsis after therapeutic intervention.1706_A Figure 1 No Caption available.1706_B Figure 2 No Caption available.