Michael Edye, MD FACS, Ramin Roohipour, MD, Leon Kushnir, MD, Barry Jaffin, MD. Mount Sinai School of Medicine, New York, N.Y.
Esophagomyotomy remains the most effective long-term solution for achalasia and results in symptomatic relief in more than 90% of patients. Failure rates have been quoted as high as 17% necessitating further endoscopic interventions such as pneumatic dilatation, re-operation, and even esophagectomy in severe cases. Revisional surgery after a failed Heller myotomy is technically demanding. This video demonstrates the preoperative work-up, intra-operative decision-making and complex operative techniques necessary to identify and correct this challenging problem.The patient was a 53 year old man who underwent an esophagomyotomy with a Dor fundoplication several months after the diagnosis of achalasia in 2008. Despite apparently adequate surgical technique as evidenced by a review of the operative report, the patient experienced rapid recurrence of symptoms including chest pain, dysphagia, and frequent regurgitation. Preoperative manometry showed an aperistaltic esophagus and a barium esophagram showed a classic ‘bird beak’ EG junction with delayed barium passage. Upper endoscopy confirmed esophageal dilatation with an anterior out-pouching present above the high pressure zone. During laparoscopic hiatal dissection air insuflation from intraoperative endoscopy revealed an area of ballooning esophageal submucosa below the diaphragm proximal to the EG junction. A narrowing with bands of raised scar tissue and muscle fibers was noted just distal to the ballooning mucosa, suggesting the site of an incomplete myotomy. To minimize bleeding, this area was divided with careful application of a reversed a Harmonic scalpel, and extended 2 centimeters onto the fundus. Re-insuflation with an endoscope revealed increased mural laxity. To maximize EG junction relaxation, a posterior myotomy was performed directly opposite the anterior revision. An anterior fundoplication was fashioned to bolster the exposed submucosa and to counter reflux. Post-operative esophagram showed prompt passage of contrast into the stomach and the patient has since reported significant and sustained improvement in swallowing and resolution of regurgitation. Failed primary esophagomyotomy poses a significant diagnostic challenge requiring careful workup. Reoperation is technically demanding necessitating critical decision making and a multi-modality approach. Anticipation of the altered anatomy due to postoperative changes and likely etiology is of paramount importance in a revision operation. Use of energy sources in contact with delicate tissues should be avoided to prevent thermal injury and perforation. Intra-operative endoscopy plays a vital role to highlight landmarks, confirm completeness of myotomy and check for leaks. Both surgeon and patient need to have realistic expectations of the possible outcomes.
Program Number: V004