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Review
. 2023 Dec 8:36:e1780.
doi: 10.1590/0102-672020230062e1780. eCollection 2023.

MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH

Francisco Tustumi  1 , Sérgio Szachnowicz  1 , Nelson Adami Andreollo  2 , Francisco Carlos Bernal da Costa Seguro  1 , Edno Tales Bianchi  1 , André Fonseca Duarte  1 , Ary Nasi  1 , Rubens Antonio Aissar Sallum  1
Affiliations
Review

MANAGEMENT OF SYMPTOMS RECURRENCE AFTER MYOTOMY FOR ACHALASIA. A PRACTICAL APPROACH

Francisco Tustumi et al. Arq Bras Cir Dig. .

Abstract
in English, Portuguese

Background: Achalasia is an esophageal motility disorder, and myotomy is one of the most used treatment techniques. However, symptom persistence or recurrence occurs in 9 to 20% of cases.

Aims: This study aims to provide a practical approach for managing the recurrence or persistence of achalasia symptoms after myotomy.

Methods: A critical review was performed to gather evidence for a rational approach for managing the recurrence or persistence of achalasia symptoms after myotomy.

Results: To properly manage an achalasia patient with significant symptoms after myotomy, such as dysphagia, regurgitation, thoracic pain, and weight loss, it is necessary to classify symptoms, stratify severity, perform appropriate tests, and define a treatment strategy. A systematic differential diagnosis workup is essential to cover the main etiologies of symptoms recurrence or persistence after myotomy. Upper digestive endoscopy and dynamic digital radiography are the main tests that can be applied for investigation. The treatment options include endoscopic dilation, peroral endoscopic myotomy, redo surgery, and esophagectomy, and the decision should be based on the patient's individual characteristics.

Conclusions: A good clinical evaluation and the use of proper tests jointly with a rational assessment, are essential for the management of symptoms recurrence or persistence after achalasia myotomy.

RACIONAL:: A acalasia é um distúrbio da motilidade esofágica e a miotomia é uma das técnicas de tratamento mais utilizadas. No entanto, a persistência ou recorrência dos sintomas ocorre em 9 a 20%.

OBJETIVOS:: Este estudo visa fornecer uma abordagem prática para o manejo da recorrência ou persistência dos sintomas de acalasia após miotomia.

MÉTODOS:: Foi realizada uma revisão crítica para reunir evidências para uma abordagem racional no manejo da recorrência ou persistência dos sintomas de acalasia após miotomia.

RESULTADOS:: Para o manejo adequado de um paciente com acalásia com sintomas significativos após miotomia, como disfagia, regurgitação, dor torácica e perda de peso, é necessário classificar os sintomas, estratificar a gravidade, realizar exames adequados e definir uma estratégia de tratamento. Uma investigação diagnóstica diferencial sistemática é essencial para cobrir as principais etiologias de recorrência ou persistência dos sintomas após a miotomia. A endoscopia digestiva alta e a radiografia digital dinâmica são os principais exames que podem ser aplicados para investigação. As opções de tratamento incluem dilatação endoscópica, POEM (miotomia endoscópica oral), remiotomia e esofagectomia, e a decisão deve ser baseada nas características individuais do paciente.

CONCLUSÕES:: Uma boa avaliação clínica e a utilização de exames adequados, juntamente com uma avaliação racional, são essenciais para o manejo da recorrência ou persistência dos sintomas após miotomia por acalasia.

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Conflict of interest statement

Conflict of interests: None

Figures

Figure 1
Figure 1. Symptoms after myotomy should be classified into one of three categories: “symptoms persistence”, “early recurrence”, or “late recurrence”. These categories help healthcare professionals to work up differential diagnoses.
Figure 2
Figure 2. Endoscopy from a patient with achalasia after a myotomy with partial fundoplication. The esophagus presents a body with augmented diameter and tortuosity, with no malignancy suspicion at the chromoendoscopy. The retroflexed view shows a normal partial fundoplication. The patient was satisfactorily treated with peroral endoscopic myotomy. The anti-reflux valve hampered the risk of post-peroral endoscopic myotomy gastroesophageal reflux.
Figure 3
Figure 3. Achalasia patient with disruption of the anti-reflux valve and distal erosive esophagitis. This patient had ineffective endoscopic dilation treatments. After a redo laparoscopic surgery, with a new myotomy and a new partial fundoplication, the patient presented improvement in dysphagia and gastroesophageal reflux.
Figure 4
Figure 4. In this patient with incomplete myotomy, the barium swallow test showed no sign of herniation and a normal fundoplication. This patient failed treatment with balloon dilation and was finally treated with laparoscopic myotomy and partial fundoplication. Peroral endoscopic myotomy could be a reasonable alternative.
Figure 5
Figure 5. The barium swallow test shows an esophagus with augmented diameter and tortuosity. The imaging test suggests that small herniation through hiatus influenced dysphagia recurrence after myotomy. A peroral endoscopic myotomy would not solve the herniation problem, and consequently, the best approach was laparoscopic revisional surgery. The hernia was corrected, and a new myotomy was performed.
Figure 6
Figure 6. This contrast radiography shows a significant valve migration. Endoscopic procedures would not correct the valve migration, and ergo, were not considered. The patient was treated with a revisional laparoscopic surgery.
See this image and copyright information in PMC

References

    1. Akimoto S, Yano F, Omura N, Tsuboi K, Hoshino M, Yamamoto SR, et al. Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy: a single-institution experience. Surg Today. 2022;52((3)):401–7. doi: 10.1007/s00595-021-02376-5. - DOI - PubMed
    1. Bianchi ET, Sallum RAA, Szachnowicz S, Seguro FCBC, Duarte AF, Rocha JRM, et al. Heller-Pinotti, a modified partial fundoplication associated with myotomy to treat achalasia: technical and final results from 445 patients. Mini-invasive Surg. 2017;1:153–9. doi: 10.20517/2574-1225.2017.41. - DOI
    1. Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet. 2014;383((9911)):83–93. doi: 10.1016/S0140-6736(13)60651-0. - DOI - PubMed
    1. Chrystoja CC, Darling GE, Diamant NE, Kortan PP, Tomlinson GA, Deitel W, et al. Achalasia-specific quality of life after pneumatic dilation or laparoscopic heller myotomy with partial fundoplication: a multicenter, randomized clinical trial. Am J Gastroenterol. 2016;111((11)):1536–45. doi: 10.1038/ajg.2016.402. - DOI - PubMed
    1. Costa LCS, Braga JGR, Tercioti V, Junior, Coelho Neto JS, Ferrer JAP, Lopes LR, et al. Surgical treatment of relapsed megaesophagus. Rev Col Bras Cir. 2020;47:e20202444. doi: 10.1590/0100-6991e-20202444. - DOI - PubMed