Management of failed Heller's operations

Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation

BACKGROUND

Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation.

METHODS

We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture.

RESULTS

A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10).

CONCLUSIONS

Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.

End-stage achalasia

Despite symptom improvement offered to achalasia patients by either pneumatic dilation or surgical myotomy, 10% to 15% of those so treated will present progressive deterioration of their esophageal function and up to 5% may eventually require an esophagectomy. The natural evolution of achalasia to its end stage as well as the timing of esophagectomy in these patients form the basis of this review. The optimal reconstruction for the decompensated resected esophagus will also be explored: gastric interposition, colon interposition, and jejunal interposition all have their respective advantages and disadvantages. Their use is examined in the exclusive context of resection for achalasia.

Revisional surgery after heller myotomy for treatment of achalasia: a comparative analysis focusing on operative approach

Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3 years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.

Inversed Y cardioplasty plus a truncal vagotomy-antrectomy and a Roux-en-Y gastrojejunostomy performed in patients with stricture of the esophagogastric junction after a failed cardiomyotomy or endoscopic procedure in patients with achalasia of the esophagus

Laparoscopic anterior cardiomyotomy in addition to anterior Dor's fundoplication is the procedure of choice for achalasia of the esophagus with approximately 95% success rate. Redo cardiomyotomy is complicated and associated with rerecurrence of dysphagia. Twelve patients with failed redo myotomy were clinically evaluated with radiology, endoscopy, and manometry in whom achalasia type III or IV was confirmed. We propose as treatment for these selected cases an inversed Y cardioplasty + truncal vagotomy, a partial distal gastrectomy and Roux-en-Y gastrojejunostomy in order to facilitate esophageal emptying and avoid the appearance of postoperative gastroesophageal reflux as a side effect of this procedure. One patient was reoperated on in order to enlarge the cardioplasty. Disappearance of dysphagia was confirmed in all patients. Three patients presented reflux symptoms and were treated with 20 mg of Omeprazole 20 twice/day. No food retention, erosive esophagitis, or Barrett's esophagus were observed. The mean resting pressure decreased from 24.9 +/- 8.5 mm Hg to 7.5 +/- 2.5 mm Hg (P = 0.0001). Furthermore, esophageal diameter decreased significantly after a 5-year follow-up. This procedure could be an option for treating patients in which repeated Heller operations have failed.

Achalasia--if surgical treatment fails: analysis of remedial surgery

INTRODUCTION

Heller myotomy leads to good-excellent long-term results in 90% of patients with achalasia and thereby has evolved to the "first-line" therapy. Failure of surgical treatment, however, remains an urgent problem which has been discussed controversially recently.

MATERIALS AND METHODS

A systematic review of the literature was performed to analyze the long-term results of failures after Heller's operation with emphasis on treatment by remedial myotomy.

DISCUSSION

Other reinterventions and their causes after failure of surgical treatment in patients with achalasia are discussed.

Laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus following failed cardiomyotomy: experience of 11 patients

INTRODUCTION

Laparoscopic myotomy is a widely used procedure and is now considered to be the treatment of choice for achalasia. Esophagectomy for achalasia is usually performed only for megaesophagus. We present our experiences with laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus due to failed Heller's myotomy.

MATERIALS AND METHODS

We managed a total of 11 patients with megaesophagus in our institute from 1993 to 2007. Work-up included investigations included endoscopy, barium swallow, and manometry. Laparoscopic transhiatal esophagectomy with gastric pull through was successfully performed for all cases.

RESULTS

The mean operating time was 317.5 min, and the mean blood requirement was 525 ml. The mean duration between the first and second procedures was 13 months. Our overall failure rate for primary surgery (myotomy) was 3.1% and overall symptomatic improvement was achieved in 82% of patients. There were no conversions.

DISCUSSION

About 10% of postmyotomy patients will have recurrence, and 5% of them need reoperation. Laparoscopic esophagectomy for sigmoid esophagus is a formidable operation due to adhesions/fibrosis at the hiatal area. Dissection of the S-shaped esophagus in the thorax is quite tedious and an accurate knowledge of the shape and location of the megaesophagus preoperatively is vital. If performed in specialized centers, laparoscopic excision is safe and effective, utilizing all the benefits of minimal access.

Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia

OBJECTIVE

To assess the causes of failure of laparoscopic Heller myotomy and to verify whether endoscopic pneumatic dilation is a feasible treatment.

SUMMARY BACKGROUND DATA

Laparoscopic Heller myotomy has proved an effective treatment for esophageal achalasia, with good or excellent results in 90% of patients. The treatment of failures remains controversial, however.

METHODS

From 1992 to 1999, 113 patients underwent laparoscopic Heller myotomy for esophageal achalasia. Ten patients (8.7%) reported dysphagia (n = 7) or chest pain (n = 3) a median of 5 months after surgery (range 1-12) and were considered surgical failures. Pre- and postoperative radiologic, manometric, and 24-hour pH monitoring findings in patients with achalasia recurrence were compared with those of 74 asymptomatic subjects.

RESULTS

The preoperative characteristics of the two groups were comparable. After surgery, a decrease in resting lower esophageal sphincter pressure was observed in both groups, whereas the abdominal and overall lengths were significantly shorter among the asymptomatic patients. No patients with recurrence had abnormal gastroesophageal reflux. Based on time to recurrence and manometric and fluoroscopic findings, the etiology of the recurrences was classified as incomplete myotomy upward (n = 1), incomplete myotomy or sclerosis of the myotomy downward (n = 7), or sigmoid megaesophagus (n = 1); in one patient the authors could not establish the etiology. Seven of nine patients were effectively treated with endoscopic pneumatic dilations (median 2 dilations, range 1-4); one refused to undergo further treatment. Two patients underwent redo surgery.

CONCLUSIONS

Recurrence of symptoms after myotomy is mainly related to incomplete myotomy or sclerosis of the distal site of the myotomy; it can be treated by dilations after surgery.