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

Robotic redo Heller myotomy: how I do it?

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia

PURPOSE

Symptom 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).

METHODS

A 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.

RESULTS

Over 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.

CONCLUSION

In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.