Incomplete Myotomy

This may occur because of scar tissue at the level of the GEJ secondary to prior endoscopic treatment [2, 7, 16–18]. Both pneumatic dilatation and intrasphincteric injection of botulinum toxin can cause scarring at the level of the GEJ with fibrosis and loss of the normal anatomic planes. In these cases, the myotomy is more difficult, perforation of the mucosa is more common , and the results are less predictable [16].

Lack of Separation of the Muscle Edges

After completion of the myotomy, it is important to separate the edges of the muscle layers so that about 30–40% of the mucosa is uncovered [2]. This step decreases the chance of reapproximation of the muscle edges distally during healing and the formation of a new scar resulting in esophageal narrowing (Fig. 9.2).

Tight Closure of the Hiatus

We do not advocate hiatal closure in the average patient with achalasia because sutures that narrow the hiatal opening may impair esophageal emptying. Hiatal closure should be considered only for the rare patient who has an associated large hiatal hernia; and in those patients, we recommend the hiatus be closed only partially to avoid persistence of dysphagia.

Wrong Type of Fundoplication

A 360° fundoplication may create a mechanical obstruction because of the lack of peristalsis in patients with achalasia (Fig. 9.3).

Wrong Configuration of the Fundoplication

Either an anterior or a posterior partial fundoplication may be a cause of persistent dysphagia. A Dor fundoplication (180° anterior) must be constructed with two rows of sutures only, one on the left and one on the right [9]. The left row should have three sutures, with the upper one incorporating the esophagus, the fundus of the stomach, and the left pillar of the crus. The second and the third stitches are placed between the fundus of the stomach and the left side of the esophageal wall (Fig. 9.4a, b). After folding the fundus over the exposed mucosa, three additional sutures are placed. The first one incorporates the fundus of the stomach, the esophagus, and the right pillar of the crus; the second and the third stitches should only incorporate the esophageal wall and the fundus . Apical stitches and transection of the short gastric vessels are also important as they avoid tension on the fundoplication.

Too many stitches at this level will cause constriction of the GEJ . Patti et al. showed that problems with the construction of a Dor fundoplication can be a cause of both persistent and recurrent dysphagia [2]. A Toupet fundoplication (240° posterior) may also cause angulation of the esophagus and problems with esophageal emptying [11].

Recurrent Dysphagia

These are patients who experience substantial relief for months or years after the initial Heller myotomy and then experience progressive dysphagia. The specific cause of recurrent dysphagia is not always easy to elucidate as progression of disease, scarring in the area of the previous Heller, or cancer may be causing it. Most common causes of recurrent dysphagia are:

Scarring of the Distal Edge of the Myotomy

When patients experience recurrent symptoms after a long symptom free interval, scarring at the distal edge of the myotomy is the most common cause (Fig. 9.5) [2, 19, 20]. While studies to date have not identified specific factors that predict this problem, we believe that a longer myotomy and a wider separation of the muscular edges of the myotomy at the time of initial operation might decrease the frequency of this problem [3, 6].

Diagnostic Evaluation

When a patient complains of recurrent dysphagia, it is important to perform a complete workup to try to identify the cause in order to formulate a tailored treatment plan [27].

The first step should always be to review the entire history – in particular that which existed before the first operation  – and to review, when possible the diagnostic tests performed before the initial operation. It is at this time that we have found that some of these patients did not have achalasia to begin with. Once this process is complete, we like to review the report of the original operation. Often there are clues that explain the symptoms, such as the description of scar tissue due to prior treatment, failure of identifying the anatomic planes, or a short myotomy .

The symptomatic evaluation is the next step. It determines which symptoms are present and compares them to the symptoms present before the first operation. In addition, it distinguishes between persistent and recurrent dysphagia.

A barium swallow is very useful to determine the cause of the dysphagia. It identifies the area of obstruction, assesses the degree of esophageal dilatation, the emptying of the barium from the esophagus into the stomach, and shows the overall shape of the esophagus. It might help distinguish between a short myotomy, a tight closure of the hiatus, and a constricting or malpositioned fundoplication. Loviscek et al. reported a series of patients with recurrent dysphagia after Heller myotomy who underwent redo surgery and were able to correlate the preoperative radiologic findings on barium swallow to the postoperative improvement in symptoms. All patients with a straight esophagus (normal or dilated caliber) had improved dysphagia after revisional surgery, whereas dysphagia improvement was less consistent if the esophagus was sigmoid in shape [27].

An upper endoscopy should be carried out in every patient as it can show if there is mucosal damage due to reflux, candida esophagitis due to slow emptying, or cancer. Endoscopic evaluation can also reveal angulation of the distal esophagus due to a malpositioned or overly tight fundoplication.

Esophageal manometry is essential to confirm the diagnosis of achalasia and to measure the pressure and relaxation of the lower esophageal sphincter. When compared to the preoperative test, it can show if the myotomy has been extended appropriately onto the gastric wall or if a residual high-pressure zone is still present.

Ambulatory 24-hour pH monitoring should be performed in patients with recurrent dysphagia. It is important to look not only at the reflux score, but to review the pH tracing to distinguish between real reflux and false reflux due to stasis and fermentation. This test should be routinely done even in asymptomatic patients after a Heller myotomy as reflux can be often “silent” [1]. This is particularly important when operating on children as a life-long exposure to reflux can cause Barrett’s esophagus or even esophageal cancer [24, 26, 28].

When pseudoachalasia secondary to the presence of cancer is suspected, endoscopic ultrasound and computed tomography can help establish the diagnosis [29].

Treatment

Revisional Surgery

If dysphagia is not relieved by dilatations, a reoperation must be considered. When consenting the patient, it is important to stress that even though most cases can be performed laparoscopically, a laparotomy might be needed. In addition, patients must be aware that in case of severe damage to the mucosa during the course of the operation, an esophagectomy may be necessary.

The first step of the operation consists in separating the liver from the stomach and the esophagus. Subsequently the fundoplication should be taken down and the fundus brought to the left in order to fully expose the esophageal wall. Once the previous myotomy has been exposed and the area of narrowing is clearly identified, we prefer to correct the problem by performing a new myotomy on the side of the anterior esophagus opposite to the first myotomy. Rather than trying to extend the prior myotomy, it is easier to perform a new myotomy on the opposite side in order to work on an unscarred part of the esophageal wall (see Fig. 9.6) [27]. The myotomy should be extended for about 2.5–3 cm below the GEJ, and intraoperative endoscopy should be performed to evaluate for inadvertent esophageal or gastric mucosal injury. After the myotomy is completed, consideration should be given whether or not to add a fundoplication. If a mucosal injury has occurred, a Dor fundoplication should be performed to cover the area of injury. In the absence of a perforation, often we do not perform a fundoplication, based on the following considerations: (a) dysphagia is the primary problem necessitating repeat intervention; (b) returning to the operating room a third time to relieve dysphagia is an increasingly difficult task; (c) occasionally a fundoplication may contribute to dysphagia; and (d) abnormal reflux can be treated medically far easier than dysphagia. Loviscek et al. recently showed excellent results using this approach [27]. The outcome of 43 achalasia patients who underwent redo Heller myotomy for recurrent dysphagia between 1994 and 2011 was analyzed. Three patients underwent take down of the previous fundoplication only, while the remaining 40 patients had that and a redo myotomy that extended for 3 cm onto the gastric wall. A fundoplication was added in one third of patients only. At a median follow-up of 63 months in 24 patients, 19 patients (79%) reported improvement of dysphagia with median overall satisfaction rating of 7 (range 3–10). Four patients required esophagectomy for persistent dysphagia . Similar results have been reported by others [30–32].

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