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

Abstract

Background: Laparoscopic 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.

Methods: Patients 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.

Results: Forty-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).

Conclusions: This 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.

Keywords: Achalasia; Esophagectomy; Laparoscopy; Myotomy; Revisional surgery.

Fig. 1

The Kaplan-Meier curve of symptom-free survival of the whole cohort of patients who underwent revisional myotomy.

Fig. 2

Manometric pressure parameters of the LES before and after redo myotomy. Preoperative (Preop) and postoperative (Postop) basal pressure (LESP) and relaxation pressure/integrated relaxation pressure (ResP/IRP) of patients with a positive (pos) and negative outcome (failed) after redo myotomy are reported. ResP/IRP was the only parameter showing a significant postoperative decrease only in patients who responded to redo myotomy (p < 0.01)

Fig. 3

The Kaplan-Meier curve of symptom-free survival after revisional surgery by radiological stage. Patients presenting with stage IV disease had a significantly lower symptom-free survival after redo myotomy compared to patients with earler stages of the disease (p = 0.0002). These patients are probably responsible of the marked decline of Fig.1 curve, after 8 years of follow-up