Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia

The Foregut questionnaire, the GERD-HRQL questionnaire, and the Atkinson and Eckardt scales were used to assess symptoms severity and frequency. Pre-treatment work-up routinely included upper gastrointestinal endoscopy and barium swallow study. Esophageal manometry and pH-impedance monitoring was performed in selected patients mainly complaining of reflux symptoms. Chest CT scan was performed in elderly individuals to rule out malignancy.

Depending on age, comorbidities, and results of objective testing, patients were first offered endoscopic PD, laparoscopic HM and Dor fundoplication, laparoscopic transgastric stapled cardioplasty, or hybrid Ivor Lewis esophagectomy. Endoscopic PD was performed after 12 h of fasting, under deep sedation or general anesthesia, depending on patient’s comorbidity and the degree of cooperation, using a 30 or 35 mm Rigiflex™ balloon (Boston Scientific, MA) fully inflated for 60 s, and the balloon inflation was repeated 3 times. Laparoscopic HM was performed after lysis of adhesions between the liver and the phrenoesophageal ligament covering the previous myotomy site which is generally at 12–2 o’clock position; if present, a prior fundoplication was taken down. A mediastinal dissection was performed to enable straightening of a sigmoid esophagus, to reduce a hiatal hernia, or to resect with a linear endostapler an esophageal pseudodiverticulum. Intraoperative endoscopy was selectively used to assist surgical dissection. The HM extended for about 5 cm above the gastroesophageal junction and for 2 cm towards the gastric side, away from the previous myotomy. The most proximal short gastric vessels were divided whenever necessary to relieve tension on the fundic flap, and a 180° anterior fundoplication (Dor) was performed. A posterior crural repair was added whenever necessary, especially when performing a Toupet fundoplication or after reduction of a sigmoid esophagus. Esophagectomy with hybrid Ivor-Lewis approach was reserved to patients with end-stage achalasia and/or multiple prior surgical procedures8 in whom a redo HM was considered futile. A laparoscopic trans-gastric stapled cardioplasty9 combined with Dor fundoplication was considered in patients with contraindications to esophagectomy. All revisional procedures were carried out by a senior expert surgeon, and the likely reason for symptom persistence/recurrence was annotated in the operative report.

Clinical and endoscopic follow-up was scheduled at yearly intervals and included symptoms questionnaires and an upper gastrointestinal endoscopy. In patients with persistent/recurrent symptoms during the follow-up, further work-up and revisional treatment was offered depending on patient’s quality of life, previous treatments, and comorbidities. At the latest follow-up, the evolution and change in symptom frequency and severity were analyzed for each patient and compared to baseline.

Categorical data are reported with frequencies and proportions. Continuous data are reported as median and interquartile range (IQR). Comparison of categorical data was performed using chi-square and Fisher exact tests. Continuous variables were compared using non-parametric tests (Mann–Whitney U test, Wilcoxon signed rank test, and Kruskal Wallis test), as appropriate. A p-value lower than 0.050 was considered statistically significant. Statistical analysis was performed using Statistical Package for the Social Sciences Software (SPSS 25.0®).

The most common revisional treatments were PD (50%) and HM with fundoplication (38.5%). There were no conversions to laparotomy. Based on intraoperative assessment, possible reasons for recurrence of symptoms after the primary surgical treatment were the following: dense periesophageal fibrosis (n=8), twisted/obstructing fundoplication (n=3), dolicho-megaesophagus (n=3), disrupted fundoplication (n=1), and pseudodiverticulum (n=1, 7.7%). One intraoperative mucosal tear occurred during redo HM, and was immediately recognized, repaired, and covered by the Dor flap. Overall postoperative morbidity rate was 7.7% and consisted of atrial fibrillation responsive to pharmacological cardioversion (n=1) and left pneumothorax requiring drainage (n=1). There was no mortality. The median hospital stay was 3 days (IQR 4). No hospital re-admissions were recorded up to 30 days after discharge (Table 2). Throughout the follow-up time, nine patients (34.6%) required repeat revisional therapy and were treated by PD (n=6), redo HM (n=2), and stapled cardioplasty (n=2) (Figures 1 and 2)

The median follow-up was 42 months (range 10–149) (Figure 2). There was a statistically significant decrease of dysphagia, regurgitation, chest pain, and respiratory symptoms compared to baseline (p<0.05) (Table 3). The overall rate of occasional (once a week or less) dysphagia was 23.0% for the entire cohort. The median Eckardt score significantly decreased from 4.0 (IQR 2.3) to 1.0 (IQR 2.0) (p<0.05). At the last endoscopic follow-up, 12 (46.2%) of the 26 patients had normal findings, whereas 5 (19.2%) had a dilated esophagus, 4 (15.4%) a tortuous distal esophagus, 2 (7.7%) grade C distal esophagitis, and 1 (3.8%) a pseudodiverticulum.

This is a retrospective study with a relatively small sample size conducted in a single institution, and these results may not be generalizable. In addition, the majority of patients presented after an initial treatment performed elsewhere, and pre- and post-treatment manometric and pH data were not available for all patients. Post-revisional manometric and pH data were not obtained. However, we used the same symptom scales for dysphagia both pre- and postoperatively and the study encompasses a very long period of time, with a median follow-up of 7 years and range from 1 to 15.5 years.