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.