Abstract
PurposeSymptom recurrence after initial surgical management of esophageal achalasia occurs in 10–25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). MethodsA retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. ResultsOver a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10–149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p<0.05) was noted. ConclusionIn specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.
Highlights
Achalasia is an esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter and loss of esophageal body peristalsis
Treatment failure rates are estimated in the range of 20–25% after endoscopic pneumatic dilation (PD) and 10–20% after laparoscopic Heller myotomy (HM).[3,4,5,6,7]
The main purpose of this study was to analyze the outcomes of revisional surgery after prior failed Heller myotomy
Summary
Achalasia is an esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter and loss of esophageal body peristalsis. Available palliative treatments are directed to alleviate symptoms and improve quality of life through reduction of sphincter resistance.[1] Initial treatment options include surgical. Heller myotomy (HM) with anterior Dor fundoplication, endoscopic pneumatic dilation (PD), and, less often, endoscopic injection of botulinum toxin. Peroral endoscopic myotomy (POEM) has been introduced as a promising therapeutic alternative.[2]. Treatment failure rates are estimated in the range of 20–25% after endoscopic PD and 10–20% after laparoscopic HM.[3,4,5,6,7] Symptom recurrence after PD is related to lack of uniform protocols, operator’s experience, and patient related factors. When symptoms persist or recur after the initial therapeutic approach, additional treatment may be required to restore a satisfactory quality of life. The main purpose of this study was to analyze the outcomes of revisional surgery after prior failed Heller myotomy
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