E. H. Bruenderman1, R. C. Martin1, M. P. Fox2, V. H. Van Berkel2, S. B. Block1, F. J. Kehdy1 1University Of Louisville,Department Of Surgery,Louisville, KY, USA 2University Of Louisville,Department Of Cardiovascular And Thoracic Surgery,Louisville, KY, USA
Introduction: Current treatments of achalasia aim to relieve the outlet obstruction at the gastroesophageal junction (GEJ) but cannot address the progressive degeneration of neurons affecting esophageal motility. Heller myotomy provides excellent short-term relief, however, long-term symptom recurrence is common. The term ‘failed myotomy’ is often used to reference symptom recurrence but has no universally accepted definition and is not addressed in SAGES guidelines, last updated in 2011. Standardizing the approach to symptom recurrence will delineate what constitutes a ‘failed myotomy’ versus progressive peristaltic failure.
Methods: Patients with achalasia who underwent laparoscopic Heller myotomy at a single center between 2013 and 2018 were reviewed and data extracted. Patient demographics and characteristics were compared. Patients with symptom recurrence were noted. Follow-up imaging studies were reviewed for objective evidence of GEJ outflow obstruction versus none. Results were used to compose an algorithm to address symptom recurrence and define ‘failed myotomy.’
Results: A total of 59 patients with a median age of 50 (range 13 to 91) years, 26 (44.1%) were male, median BMI was 27.76 (range 16.13 to 49.03), 18 (30.5%) had undergone prior Botox injection, 30 (50.8%) had undergone prior dilation. Fundoplication was performed on 21 (35.6%) patients. Median follow-up was 3 (range 0.5 to 60) months. Symptom recurrence occurred in 23 (39.0%) patients, with a median interval to recurrence of 13 (range 0.5 to 45) months. Of those with symptom recurrence, 15 (65.2%) underwent repeat upper gastrointestinal series (UGI), with 7 showing narrowing at the LES. Of 17 (73.9%) who underwent repeat EGD, 4 showed narrowing at the LES. Of 5 (21.7%) who underwent repeat high resolution manometry (HRM), 1 revealed impairment of LES relaxation. One (4.3%) patient was lost to follow-up prior to undergoing repeat imaging. A total of 7 (30.4% of recurrence cohort, 11.9% of total cohort) patients with symptom recurrence required repeat intervention – 4 dilations, 1 dilation and subsequent POEM, 1 redo Heller myotomy, and 1 lost to follow-up before intervention. A diagnostic algorithm for recurrence was created, defining ‘failed myotomy’ as symptom recurrence after myotomy, with objective findings confirming GEJ outflow obstruction, either on HRM alone, or on UGI and subsequent EGD.
Conclusion: Treatment of achalasia aims to relieve a hypertensive LES. Symptom recurrence occurs frequently, underscoring the importance of distinguishing a true ‘failed myotomy’ from the progressive degeneration of peristalsis that characterizes achalasia. Objective evidence of GEJ outflow obstruction in the form of UGI with EGD, and/or HRM, is crucial to label recurrence as a ‘failed myotomy’ and direct further treatment. We propose updated guidelines to reflect this common issue in the treatment of achalasia.