Failed Heller Myotomy Research Articles

Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5years.

Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM. Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES)≤3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM. Seventy-two cases (45.9±13.4years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7±3.3cm, and mean procedure duration was 59.2±25.9min. There was significant improvement in ES (pre-POEM 6.5±1.8 vs post-POEM 0.7±0.7), lower esophageal sphincter pressure pressures (31.7±12.5 vs 13.3±5.7mmHg) and barium emptying (14.2±4.2 vs 2.4±3.1cm) after POEM. At a median follow-up of 63months (IQR 40-95), clinical success (ES≤3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively. POEM is a durable treatment modality in cases with relapse of symptoms after HM.

Robotic redo Heller myotomy: how I do it?

Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.

Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience.

To compare the surgical outcomes of redo laparoscopic Heller-Dor procedure and rescue peroral endoscopic myotomy for patients with failed Heller myotomy. We identified patients who had undergone redo laparoscopic Heller-Dor procedure or rescue peroral endoscopic myotomy from August 1996 to September 2019 and assessed the patients' characteristics, timed barium swallow results, symptom scores before/after surgery, surgical outcomes, and postoperative outcomes. Eleven patients underwent redo laparoscopic Heller-Dor procedure, and 14 underwent rescue peroral endoscopic myotomy. Blood loss (p = 0.001) and intraoperative complications rate (p = 0.003) were lower and the operative time (p > 0.001) and observation period (p = 0.009) shorter in patients who underwent rescue peroral endoscopic myotomy than in patients who underwent redo laparoscopic Heller-Dor procedure. Patients who underwent rescue peroral endoscopic myotomy had a higher rate of postoperative reflux esophagitis (p = 0.033) than those who underwent redo laparoscopic Heller-Dor procedure. After the interventions, the dysphagia symptoms were improved for both groups. Furthermore, both groups expressed satisfaction with their respective procedures. Rescue peroral endoscopic myotomy was associated with better surgical outcomes than redo laparoscopic Heller-Dor for patients with failed Heller myotomy. However, rescue peroral endoscopic myotomy had higher rates of postoperative reflux esophagitis.

Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia

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.

Laparoscopic Revisional Surgery After Failed Heller Myotomy for Esophageal Achalasia: Long-Term Outcome at a Single Tertiary Center

BackgroundLaparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10–20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM. MethodsPatients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment. ResultsForty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003). ConclusionsThis study reports the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.

Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients?

Laparoscopic Heller myotomy fails in approximately 3.5% to 15% of patients. Evidence of successful laparoscopic reoperation is limited to a few studies. This case-control study was conducted in patients who underwent laparoscopic Heller myotomy reoperation (LHM-R) from 2008 to 2016. The operative outcomes, preoperative and last follow-up manometric parameters, and symptom questionnaire results, including the Eckardt, Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and eating assessment tool (EAT-10) scores, were obtained. The data were compared with those of patients who underwent primary laparoscopic Heller myotomy (LHM-1). Thirty-five patients who underwent LHM-R and 35 patients who underwent LHM-1 were included. The reasons for failure in the LHM-R patient group included incomplete myotomy (71.4%), myotomy fibrosis (25.7%) and structural alterations in fundoplication (2.9%). The follow-up duration was 34months for the LHM-R group and 24months for the LHM-1 group (p = 0.557). The procedure was performed by laparoscopy in 100% of the patients in the two groups. No differences were found regarding surgical morbidity (11.4% LHM-R vs. 2.9% LHM-1, p = 0.164). The symptomatic outcomes were equivalent between groups (Eckardt p = 0.063, EAT-10 p = 0.166, GERD-HRQL p = 0.075). An IRP < 15mmHg was achieved in 100% of the LHM-R and LHM-1 patients. At the last follow-up, 82.1% of the LHM-R patients and 91.4% of the LHM-1 patients were in symptomatic remission (p = 0.271). The results achieved with LHM-R are similar to those achieved with LHM-1. Laparoscopic reoperation should be considered an effective and safe treatment after a failed Heller myotomy.

Efficacy and safety of peroral endoscopic myotomy in the management of recurrent achalasia after failed Heller myotomy: a systematic review and meta-analysis.

BackgroundHeller myotomy (HM) is an established treatment for achalasia but can fail in up to 10-20% of patients. Peroral endoscopic myotomy (POEM) may be an appropriate treatment for patients with failed HM.MethodsWe searched several databases to identify non-comparative studies evaluating the efficacy and/or safety of POEM after failed HM and comparative studies comparing the efficacy and/or safety of POEM in patients with and without prior HM. Outcomes assessed included clinical success, technical success, adverse events, post-treatment gastroesophageal reflux disease (GERD), and presence of esophagitis on endoscopy. We calculated weighted pooled rates with 95% confidence intervals (CI) for all outcomes in patients undergoing POEM with prior HM. We calculated pooled odds ratios with 95%CI to compare the outcomes between patients with and without previous HM who underwent POEM.ResultsWe included 11 observational studies with 1205 patients. Weighted pooled rates (95%CI) for overall clinical success and technical success in patients with failed HM were 87% (81-91%) and 97% (94-99%), respectively. Weighted pooled rates (95%CI) for major adverse events, new-onset GERD and presence of esophagitis on endoscopy were 5% (2-10%), 33% (26-41%), and 38% (22-58%), respectively. There were no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM.ConclusionsPOEM is safe and effective in patients with failed HM and should be considered in patients with recurrent achalasia after HM. Outcomes of POEM are comparable in patients with and without prior HM.

PS01.012: LAPAROSCOPIC REMEDIAL MYOTOMY FOR RECURRENT ESOPHAGEAL ACHALASIA

Abstract Background Revisional surgery is sometimes necessary after failed laparoscopic Heller myotomy for esophageal achalasia. We evaluated the feasibility complications and final outcome of laparoscopic revisional myotomy (LRM) for recurrent esophageal achalasia. Methods Post-operative outcome after LRM at our Institution between 2000 and 2017 was assessed by a symptom questionnaire, endoscopy, barium swallow and pH-monitoring. Results Forty-one patients underwent LRM: 7 from our series, 34 from elsewhere. Primary treatments included laparoscopic (20 pts) or open (5) Heller-Dor; laparoscopic (6) or open (7) Heller-Nissen; 3 pts had open myotomy only. Thirty-four pts (83%) underwent a median of 3 (1–6) pneumatic dilations (PD) between primary operation and LRM. All the operations were performed laparoscopically. The median operating time was 180 minutes (65–260). One patient was converted to open for a mucosal lesion. The fundoplication was dismounted, when present. A new myotomy, longer than the previous one (especially on the gastric side), was performed in a healthy tissue, on a different quadrant of the esophageal wall. A fundoplication was reconstructed in 29 patients (70.7%) by performing a Dor (24 pts) or a Toupet (5) procedure. Two patients needed laparoscopic revision on 2nd post-operative day (POD) for radiological evidence of an obstructive fundoplication. One patient required revision on 2nd POD for a leakage, treated by suture and conversion from a Toupet to a Dor. Median follow-up time was 76 months (2–179). After revisional surgery, 27 pts had a resolution of their symptoms (66%), whereas other 6 (14.6%) needed further PD to achieve a satisfactory outcome. Other 4 patients (9.8%) still need periodic PD and 3 patients (7.3%) required esophageal resection. Endoscopic gastrostomy was necessary in one patient (2.4%) who wasn’t suitable for resection. Reflux was detected in 11 patients (26.8%). Conclusion LRM is feasible when primary surgery has failed. One-third of the patients still require repeat dilations or esophagectomy, especially in case of megaesophagus. Albeit this is a more difficult operation and carries significant morbidity, LRM may provide the resolution of symptoms to an overall 80% of this group of patients, highly refractory to standard treatments. Disclosure All authors have declared no conflicts of interest.

Tu1180 OPEN PERORAL ENDOSCOPIC MYOTOMY FOR THE TREATMENT OF ACHALASIA: A MINIMALLY INVASIVE TECHNIQUE

Peroral Endoscopic Myotomy(POEM) is safe and effective for most patients with achalasia but creation of the submucosal tunnel during the POEM procedure is still challenging for patients with failed Heller myotomy or sigmoid-shaped esophagus. Inspired by the success of POEM for the treatment of achalasia, we investigated a method of direct peroral endoscopic myotomy without a submucosal tunnel for the treatment of achalasia, which we call Open Peroral Endoscopic Myotomy (O-POEM). This study aimed to evaluate the feasibility and efficacy of O-POEM for patients with failed Heller myotomy or sigmoid-shaped esophagus. In this study, O-POEM was performed in 3 patients with sigmoid-type achalasia (S1 type in 1 patient and S2 type in 2 patients) and 2 achalasia patients with failed Heller myotomyat West China Hospital, a tertiary referral center in China between August 2016 and December 2016. A retrospective analysis was conducted, including the rate of symptom relief during follow-up, defined as an Eckardt score of ≤ 3, an Eckardt score, manometry, timed barium esophagram, procedure-related adverse events, reflux symptoms, and recurrence during follow-up. O-POEM was achieved successfully in all the patients. The mean operation time was 23.8 min (range 19-28 min). A reduction of Eckardt score and a timed barium esophagogram were observed during follow-up. There were no severe complications and no recurrences at 12 to 15 months of follow-up. O-POEM is a feasible and effective endoscopic treatment modality for achalasia with failed Heller myotomy or sigmoid-shaped esophagus. The O-POEM procedure for the treatment of achalasia is easier and less time-consuming. The short-term outcomes of O-POEM for achalasia were excellent, resulting in short-term symptom relief in all cases without serious complications.

What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review.

Background:Surgical treatment of achalasia fails in 10%–20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm.Materials and Methods:The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'.Results:A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified.Conclusions:The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.

Is POEM an Option for Achalasia After Failed Heller Myotomy

Recent recommendations by esophageal experts have positioned peroral endoscopic myotomy (POEM) as a safe and effective option for patients with

POEM for special patient cohorts: A review.

Peroral endoscopic myotomy (POEM) is a natural orifice, translumenal endoscopic surgical procedure that achieves endoscopic myotomy by conducting a submucosal tunnel as an operating space. It is conventionally performed in achalasia. Recently, several centers worldwide have reported the feasibility of this procedure not only in early achalasia but also in other particular patient cohorts. Possible indications for POEM include previously failed Heller myotomy, pneumatic balloon dilatation or POEM, sigmoid achalasia, pediatric patients, spastic esophagus disorders, Zenker's diverticulum and gastroparesis. However, its application in large numbers of special patient groups awaits knowledge of the long-term outcome and greater experience with POEM.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy.

In patients with persistent symptoms after Heller myotomy (HM), treatment options includerepeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluatedthe efficacy and safety of POEM in patients with achalasia with prior HM vs without priorHM. We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n= 90) and those without prior HM (non-HM group; n= 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non-HM group (P= .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non-HM group (94%; P= .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non-HM group; P= .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Efficacy of pneumodilation in achalasia after failed Heller myotomy.

Heller myotomy is an effective treatment for the majority of achalasia patients. However, a small proportion of patients suffer from persistent or recurrent symptoms after surgery and they are usually subsequently treated with pneumodilation (PD). Data on the efficacy of PD as secondary treatment for achalasia are scarce. Therefore, this study aimed to investigate the efficacy of PD as treatment for achalasia patients suffering from persistent or recurrent symptoms after Heller myotomy. Patients with recurrent or persistent symptoms (Eckardt score >3) after Heller myotomy were selected. Patients were treated with PD, using a graded distension protocol with balloon sizes ranging from 30 to 40 mm. After each dilation symptoms were assessed to evaluate whether a subsequent dilation with a larger balloon size was required. Patients with recurrent or persistent symptoms (Eckardt score >3) after treatment with a 40-mm balloon were identified as failures. Twenty-four patients were included in total; 15 patients with achalasia type I, seven with achalasia type II and two with achalasia type III. Median relapse time was 2.5 years after Heller myotomy (IQR: 9 years and 3 months). Three patients were not suitable for PD; one patient was morbidly obese and not fit for any form of sedation and two had a siphon-shaped esophagus leaving 21 patients to treat. Eight patients were successfully treated with a single 30-mm balloon dilation (median follow-up time: 6.5 years; IQR: 7.5 years). Four patients required dilations with 30- and 35-mm balloons (median follow-up time: 11 years; IQR: 3 years). Nine patients failed on the 35-mm balloon dilation and underwent a subsequent dilation with a 40-mm balloon, and all failed on this balloon as well. Thus, PD was successful in 12 of the 21 treatable patients, resulting in a success rate of 57% for treatable patients or 50% for all patients. Baseline Eckardt scores were also higher in those that failed (median: 8; IQR: 2) than those that were treated successfully (median: 5.5; IQR: 2) treated (p = 0.009). Furthermore, baseline barium column height at 5 min was higher in patients with failed (median: 6 cm; IQR: 6 cm) treatment than in patients with successful (median: 2.6 cm; IQR: 4.7 cm) treatment (p = 0.016). Baseline lower esophageal sphincter pressure was not different between patients who were treated successfully (median: 11 mmHg; IQR: 5 mmHg) and those that failed on PD (median: 17.5 mmHg; IQR: 10.8 mmHg) treatment (p > 0.05). Baseline symptom pattern was also not a predictor of successful treatment. No adverse events were recorded during or after PD. Pneumodilation for recurrent symptoms after previous Heller myotomy is safe and has a modest success rate of 57%, using 30- and 35-mm balloons. Patients with recurrent symptoms after PD with 35-mm balloon are likely to also fail after subsequent dilation with a 40-mm balloon.

874 Comparative Evaluation of PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia in Patients With Failed Heller Myotomy vs Patients Without a History of Surgical Myotomy: A Multicenter Retrospective Cohort Study

874 Comparative Evaluation of PerOral Endoscopic Myotomy (POEM) for the Treatment of Achalasia in Patients With Failed Heller Myotomy vs Patients Without a History of Surgical Myotomy: A Multicenter Retrospective Cohort Study

Assessment of Pneumatic Balloon Dilation in Patients with Symptomatic Relapse after Failed Heller Myotomy: A Single Center Experience.

BACKGROUND Although Heller myotomy is one of the most effective treatments for achalasia, it may be associated with early or late symptom relapse in some patients. Therefore, additional treatment is required to achieve better control of symptoms. Aim: To evaluate the safety and efficacy of pneumatic balloon dilation (PBD) in patients with symptom relapse after Heller myotomy. METHODS Thirty six post-myotomy patients were evaluated from 1993 to 2013. Six patients were excluded from the analysis because of comorbid diseases or epiphrenic diverticula. Thirty patients were treated with PBD. Primary outcome was defined as a decrease in symptom score to 4 or less and a reduction greater than 80% from the baseline in the volume of barium in timed barium esophagogram in 6 weeks. Achalasia symptom score (ASS) was assessed at 1.5, 3, 6, and 12 months after treatment and then every six months in all patients and PBD was repeated in case of symptom relapse (ASS>4). RESULTS The mean age of the patients was 45.5±13.9 years (range: 21-73). Primary outcome was observed in 25 patients (83%). The mean ASS of the patients dropped from 7.8 before treatment to 1.3±2.0 at 1.5 months after treatment (p=0.0001). The mean volume and height of barium decreased from 43.1±33.4 and 7.1±4.7 to 6.0±17.1 and 1.1±2.2, respectively (p=0.003, p=0.003). The mean duration of follow-up was 11.8±6.3 years. At the end of the study, 21 patients (70%) reported sustained good response. No major complications such as perforation or gross bleeding were seen. CONCLUSION PBD is an effective and safe treatment option for achalasia in patients with symptom relapse after Heller myotomy.

Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video)

Peroral endoscopic myotomy (POEM) has recently been described as a scar-free and less-invasive surgical myotomy option for treating achalasia. 1 Inoue H. Minami H. Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010; 42: 265-271 Crossref PubMed Scopus (1164) Google Scholar , 2 Zhou P.H. Yao L.Q. Zhang Y.Q. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia: 205 cases report. Gastrointest Endosc. 2012; 75: AB132-AB133 Abstract Full Text Full Text PDF Google Scholar , 3 von Renteln D. Inoue H. Minami H. et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol. 2012; 107: 411-417 Crossref PubMed Scopus (287) Google Scholar , 4 Swanstrom L.L. Kurian A. Dunst C.M. et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg. 2012; 256: 659-667 Crossref PubMed Scopus (242) Google Scholar , 5 Zhou P.H. Li Q.L. Yao L.Q. et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy. 2013; 45: 161-166 Crossref PubMed Scopus (134) Google Scholar This procedure incorporates concepts of natural orifice transluminal endoscopic surgery and achieves endoscopic myotomy by using a submucosal tunnel as the operating space. Initial published experience in humans is more than encouraging despite a relatively short follow-up.

Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study

Recurrence/persistence of symptoms occurs in approximately 20 % of patients after Heller myotomy for achalasia. Controversy exists regarding the therapy for patients in whom Heller myotomy has failed. The aim of the current study was to evaluate the efficacy and feasibility of peroral endoscopic myotomy (POEM), a new endoscopic myotomy technique, for patients with failed Heller myotomy. A total of 12 patients with recurrence/persistence of symptoms after Heller myotomy, as diagnosed by established methods and an Eckardt score of ≥ 4, were prospectively included. The primary outcome was symptom relief during follow-up, defined as an Eckardt score of ≤ 3. Secondary outcomes were procedure-related adverse events, lower esophageal sphincter (LES) pressure on manometry, reflux symptoms, and medication use before and after POEM. All 12 patients underwent successful POEM after a mean of 11.9 years (range 2 - 38 years) from the time of the primary Heller myotomy. No serious complications related to POEM were encountered. During a mean follow-up period of 10.4 months (range 5 - 14 months), treatment success was achieved in 11/12 patients (91.7 %; mean score pre- vs. post-treatment 9.2 vs. 1.3; P < 0.001). Mean LES pressure was 29.4 mmHg pre-treatment and 13.5 mmHg post-treatment (P < 0.001). One patient developed mild reflux symptoms and required intermittent medication with proton pump inhibitors. POEM seems to be a promising new treatment for failed Heller myotomy resulting in short-term symptom relief in > 90 % of cases. Previous Heller myotomy may make subsequent endoscopic remyotomy more challenging, but does not prevent successful POEM.

Pneumatic dilation or myotomy for achalasia?

Pneumatic dilation or myotomy for achalasia?

Laparoscopic re-operation for failed Heller myotomy

Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require re-operation to control persistent or recurrent symptoms. We report follow-up of 15 patients who underwent laparoscopic re-operation for failed Heller myotomy. Between 1993 and 2004, 15 patients underwent laparoscopic re-operation for failed Heller myotomy at our center. The mean duration between procedures was 23 months. Follow-up was completed at a mean duration of 30 months in 14 patients (93%) via a telephone questionnaire. Our overall failure rate for primary surgery (n = 106) was 5.6%. The mechanisms of failure were incomplete myotomy (33%), myotomy fibrosis (27%), fundoplication disruption (13%), too tight fundoplication (7%) and a combination of myotomy fibrosis and incomplete myotomy (20%). Significant symptom improvement was observed with postoperative symptom resolution seen in 71% of patients with dysphagia, 89% for regurgitation, 58% for heartburn and 40% for chest pain. Fifty percent reported excellent results and 79% would recommend the procedure to a friend. Subsequent dilations were performed in four patients (29%). Two patients required conversion to open surgery (13%). Three patients (20%) failed the re-operation and required further revisional surgery. Complications included intraoperative perforation in three (none of which resulted in postoperative morbidity) and a pneumothorax in one patient. Prior endoscopic therapies (pneumatic dilation or Botulinum toxin) were not associated with poor results. Laparoscopic re-operation for failed Heller myotomy is feasible and results are encouraging.