Advertisement

Persistent or Recurrent Symptoms After Heller Myotomy for Achalasia: Evaluation and Treatment

  • Marco G. PattiEmail author
  • Francisco Schlottmann
  • Marco Di Corpo
Chapter

Abstract

Esophageal achalasia is a primary esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter in response to swallowing and absent esophageal peristalsis. The treatment is palliative, and it is directed toward elimination of the functional obstruction caused by the non-relaxing lower esophageal sphincter. Pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic myotomy with a partial fundoplication are the available treatment modalities, and they all have a very high initial success rate. Unfortunately, because treatment is palliative, a large percentage of patients will eventually experience recurrence of symptoms during their lifetime, requiring additional treatment. In these patients, it is important to perform a careful workup to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. Esophagectomy should be considered an ultimate option. In patients who have failed other treatment modalities and whose quality of life is still negatively affected by the disease, the best results are obtained by a multidisciplinary team approach, in centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this rare disease.

Keywords

Esophageal achalasia Eckardt score Botulinum toxin injection Endoscopic dilatation Peroral endoscopic myotomy Laparoscopic myotomy Dor fundoplication Toupet fundoplication End-stage achalasia Esophagectomy 

Notes

Conflicts of Interest

The authors have no conflicts of interest to declare.

References

  1. 1.
    Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg. 1999;230:587–93.CrossRefGoogle Scholar
  2. 2.
    Patti MG, Molena D, Fisichella PM, Whang K, Yamada H, Perretta S, Way LW. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg. 2001;136:870–7.CrossRefGoogle Scholar
  3. 3.
    Oelschlager BK, Chang L, Pellegrini CA. Improvedoutcomeafterextendedgastricmyotomy for achalasia. Arch Surg. 2003;138:490–5.CrossRefGoogle Scholar
  4. 4.
    Patti MG, Fisichella PM, Perretta S, Galvani C, Gorodner MV, Robinson T, Way LW. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg. 2003;196:698–703.CrossRefGoogle Scholar
  5. 5.
    Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405–12.CrossRefGoogle Scholar
  6. 6.
    Wright AS, Williams CW, Pellegrini CA, Oelschlager BK. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc. 2007;21:713–8.CrossRefGoogle Scholar
  7. 7.
    Sweet MP, Nipomnick I, Gasper WJ, Bagatelos K, Ostroff JW, Fisichella PM, Way LW, Patti MG. The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg. 2008;12:159–65.CrossRefGoogle Scholar
  8. 8.
    Wang YR, Dempsey DT, Friedenberg FK, Richter JE. Trends of Heller myotomy hospitalizations for achalasia in the United States, 1993–2005: effect of surgery volume on perioperative outcomes. Am J Gastroenterol. 2008;103:2454–64.CrossRefGoogle Scholar
  9. 9.
    Patti MG, Fisichella PM. Laparoscopic Heller myotomy and dor fundoplication for esophageal achalasia. How I do it. J Gastrointest Surg. 2008;12:764–6.CrossRefGoogle Scholar
  10. 10.
    Zaninotto G, Costantini M, Rizzetto C, Zanatta L, Guirroli E, Portale G, Nicoletti L, Cavallin F, Battaglia G, Ruol A, Ancona E. Four hundred laparoscopic myotomies for esophageal achalasia: a single centre experience. Ann Surg. 2008;248:986–893.CrossRefGoogle Scholar
  11. 11.
    Tatum RP, Pellegrini CA. How I do it: laparoscopic Heller myotomy with Toupet fundoplication for achalasia. J Gastrointest Surg. 2009;13:1120–4.CrossRefGoogle Scholar
  12. 12.
    Patti MG, Herbella FA. Fundoplication after laparoscopic Heller myotomy for esophageal achalasia: what type? J Gastrointest Surg. 2010;14:1453–8.CrossRefGoogle Scholar
  13. 13.
    Roll GR, Ma S, Gasper WJ, Patti M, Way LW, Carter J. Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age. Surg Endosc. 2010;24:2562–6.CrossRefGoogle Scholar
  14. 14.
    Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, Pierce RA, Pryor A, Martin V, Frisella MM, Cassera M, Brunt LM. Laparoscopic dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012;26:18–26.CrossRefGoogle Scholar
  15. 15.
    Pellegrini C, Wetter LA, Patti M, Leichter R, Mussan G, Mori T, Bernstein G, Way L. Thoracoscopicesophagomyotomy. Initialexperience with a new approach for the treatment of achalasia. Ann Surg. 1992;216:291–6.CrossRefGoogle Scholar
  16. 16.
    Patti MG, Feo CV, Arcerito M, De Pinto M, Tamburini A, Diener U, Gantert W, Way LW. Effects of previous treatment on results of laparoscopic Heller myotomy for achalasia. Dig Dis Sci. 1999;44:2270–6.CrossRefGoogle Scholar
  17. 17.
    Snyder CW, Burton RC, Brown LE, Kakade MS, Finan KR, Hawn MT. Multiple preoperative endoscopic interventions are associated with worse outcomes after laparoscopic Heller myotomy for achalasia. J Gastrointest Surg. 2009;13:2095–103.CrossRefGoogle Scholar
  18. 18.
    Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than Heller myotomy alone. Ann Surg. 2006;243:579–84.CrossRefGoogle Scholar
  19. 19.
    Zaninotto G, Costantini M, Portale G, Battaglia G, Molena D, Carta A, Costantino M, Nicoletti L, Ancona E. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Ann Surg. 2002;235:186–92.CrossRefGoogle Scholar
  20. 20.
    Gockel I, Junginger T, Eckardt VF. Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation. Arch Surg. 2007;142:1093–7.CrossRefGoogle Scholar
  21. 21.
    Rossetti G, Brusciano L, Amato G, Maffettone V, Napolitano V, Russo G, Izzo D, Russo F, Pizza F, Del Genio G, Del Genio A. A total fundoplication is not an obstacle to esophageal emptying after heller myotomy for achalasia: results of a long-term follow up. Ann Surg. 2005;241:614–21.CrossRefGoogle Scholar
  22. 22.
    Zhu ZJ, Chen LQ, Duranceau A. Long-term result of total versus partial fundoplication after esophagomyotomy for primary esophageal motor disorders. World J Surg. 2008;32:401–7.CrossRefGoogle Scholar
  23. 23.
    Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg. 2008;248:1023–30.CrossRefGoogle Scholar
  24. 24.
    Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg. 2006;243:196–203.CrossRefGoogle Scholar
  25. 25.
    Patti MG, Diener U, Molena D. Esophageal achalasia: preoperative assessment and postoperative follow-up. J Gastrointest Surg. 2001;5:11–2.CrossRefGoogle Scholar
  26. 26.
    Lopes AB, Fagundes RB. Esophageal squamous cell carcinoma –precursor lesions and early diagnosis. World J Gastrointest Endosc. 2012;4:9–16.CrossRefGoogle Scholar
  27. 27.
    Loviscek MF, Wright AS, Hinojosa MW, Petersen R, Pajitnov D, Oelschlager BK, Pellegrini CA. Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer? J Am Coll Surg. 2013;216:736–43.CrossRefGoogle Scholar
  28. 28.
    Patti MG, Albanese CT, Holcomb GW 3rd, Molena D, Fisichella PM, Perretta S, Way LW. Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. J Pediatr Surg. 2001;36:1248–51.CrossRefGoogle Scholar
  29. 29.
    Moonka R, Patti MG, Feo CV, Arcerito M, De Pinto M, Horgan S, Pellegrini CA. Clinical presentation and evaluation of malignant pseudoachalasia. J Gastrointest Surg. 1999;3:456–61.CrossRefGoogle Scholar
  30. 30.
    Iqbal A, Tierney B, Haider M, Salinas VK, Karu A, Turaga KK, Mittal SK, Filipi CJ. Laparoscopic re-operation for failed Heller myotomy. Dis Esophagus. 2006;19:193–9.CrossRefGoogle Scholar
  31. 31.
    Grotenhuis BA, Wijnhoven BP, Myers JC, Jamieson GG, Devitt PG, Watson DI. Reoperation for dysphagia after cardiomyotomy for achalasia. Am J Surg. 2007;194:678–82.CrossRefGoogle Scholar
  32. 32.
    Wang L, Li YM. Recurrent achalasia treated with Heller myotomy: a review of the literature. World J Gastroenterol. 2008;14:7122–6.CrossRefGoogle Scholar
  33. 33.
    Robinson TN, Galvani CA, Dutta SK, Gorodner MV, Patti MG. Laparoscopic treatment of recurrent dysphagia following transthoracic myotomy for achalasia. J Laparoendosc Adv Surg Tech A. 2003;13:401–3.CrossRefGoogle Scholar
  34. 34.
    Swanstrom LL, Kurian A, Dunst CM, Sharata A, Bhayani N, Rieder E. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg. 2012;256:659–67.CrossRefGoogle Scholar
  35. 35.
    Hungness ES, Teitelbaum EN, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, Soper NJ. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg. 2013;17:228–35.CrossRefGoogle Scholar
  36. 36.
    Pinotti HW, Cecconello I, da Rocha JM, Zilberstein B. Resection for achalasia of the esophagus. Hepato-Gastroenterology. 1991;38:470–3.PubMedGoogle Scholar
  37. 37.
    Devaney EJ, Lannettoni MD, Orringer MB, Marshall B. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg. 2001;72:854–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Marco G. Patti
    • 1
    • 2
    Email author
  • Francisco Schlottmann
    • 3
    • 4
  • Marco Di Corpo
    • 5
  1. 1.Departments of SurgeryCenter for Esophageal Diseases and Swallowing, University of North CarolinaChapel HillUSA
  2. 2.Department of MedicineCenter for Esophageal Diseases and Swallowing, University of North CarolinaChapel HillUSA
  3. 3.Department of SurgeryHospital Alemán of Buenos Aires, University of Buenos AiresBuenos AiresArgentina
  4. 4.Department of SurgeryUniversity of North CarolinaChapel HillUSA
  5. 5.Departments of SurgeryUniversity of North CarolinaChapel HillUSA

Personalised recommendations