Recurrent dysphagia after Heller myotomy: is esophagectomy always the answer?

Esophagectomy has been recommended for patients when recurrent dysphagia develops after Heller myotomy for achalasia. My colleagues and I prefer to correct the specific anatomic problem with redo myotomy and preserve the esophagus. We examined the results of this approach.

We analyzed the course of 43 patients undergoing redo Heller myotomy for achalasia between 1994 and 2011 with at least 1-year of follow-up. In 2012, a phone interview and a symptoms questionnaire were completed by 24 patients.

Forty-three patients underwent redo Heller myotomy. All patients had dysphagia, 80% had had multiple dilations. Manometry confirmed the diagnosis, lower esophageal sphincter pressure averaged 17 mmHg; 24-hour pH monitoring was not useful because of fermentation; patients were divided into 4 groups according to findings on upper gastrointestinal series. Three patients underwent take down of previous fundoplication only, the remainder 40 had that and a redo myotomy with 3-cm gastric extension. Two mucosal perforations were repaired with primary closure and Dor fundoplication. At a median follow-up of 63 months, 19 of 24 patients reported improvement in dysphagia, with median overall satisfaction rating of 7 (range 3 to 10); 4 patients required esophagectomy for persistent dysphagia.

The majority of failures after Heller myotomy present with dysphagia associated with esophageal narrowing. Upper gastrointestinal series is most useful to plan therapy and predicts outcomes. With few exceptions, patients improve substantially with redo myotomy, which can be accomplished laparoscopically with relatively low risk. These findings challenge the previously held concept that all myotomy failures need to be treated by an esophagectomy.