B R Veenstra, MD1, R F Goldberg, MD2, S P Bowers, MD1, M Buchanan1, J A Stauffer, MD1, H J Asbun, MD1, C D Smith, MD1. 1Mayo Clinic of Florida, 2Maricopa Integrated Health System
Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10% of patients, most of whom will seek repeat surgical intervention. These re-operations are technically challenging and as such, there exist only limited reports of re-operation with esophageal preservation in these patients. Our study is an update of our center’s experience with re-operative esophagogastric myotomy in the treatment of achalasia.
Methods and Procedures:
We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to September 2014 for obstructed swallowing after prior esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of adequacy of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. Endpoints examined were intra-operative esophagogastric perforation, postoperative leak, and response to re-intervention.
A total of 56 patients who underwent 59 elective re-operations were identified. There were two patients with sigmoid mega-esophagus who underwent McKeown esophagectomy, and one patient with a non-dilatable peptic stricture who underwent Ivor-Lewis esophagectomy as our initial re-operation. The remaining 53 patients underwent 56 re-operations with the goal of esophageal preservation. Of these 56, 46 were first-time re-operations; 8 were second-time; and 2 were third-time re-operations. Of these 53 patients, 40 had prior operations via a trans-abdominal approach, 11 via a thoracic approach, and two via both approaches. All re-operations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 57% of patients (n=32), fundoplication failure in 23% (n=13), extensive fibrosis in 18% (n=10), and mucosal stricture in 2% (n=1). Intra-operative esophagogastric perforations occurred and were repaired in 19% of patients (n=10). A post-operative leak rate of 5% was identified (n=3). Three patients failed a strategy of esophageal preservation and eventually required esophagectomy, while esophageal preservation was possible in 53 of the 56 operations in which it was attempted (95%). Recurrent dysphagia after re-operation was seen in 8% of those who were identified with a failed wrap versus 32% with inadequate myotomy, 40% with fibrosis, and 100% with mucosal stricture (p=0.08 Fisher’s Exact Test).
Laparoscopic re-operation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for complete relief of dysphagia with re-operative intervention.