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What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A
Sonia Fernandez-Ananin1, Arnulfo F Fernández2, Carmen Balagué1
1Department of General and Digestive Surgery, Hospital De La Santa Creu I Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
Background:
Surgical treatment of achalasia fails in 10%-20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm.
Materials And Methods:
The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'.
Results:
A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified.
Conclusions:
The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.
Insights
Treatment options for failed achalasia surgery include pneumatic dilatation, surgical revision, and peroral endoscopic myotomy (POEM). An algorithm can guide the best approach for recurrent achalasia after initial myotomy.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Clinical Outcomes
Background:
- Achalasia treatment failure occurs in 10%-20% of patients, often due to incomplete primary myotomy.
- Effective treatment strategies for failed achalasia surgery are not well-defined.
- This study evaluates therapeutic options for recurrent achalasia post-myotomy.
Purpose of the Study:
- To review and evaluate treatments for failed surgical myotomy in achalasia.
- To define the benefits and outcomes of different treatment modalities.
- To propose a therapeutic algorithm for managing achalasia treatment failure.
Main Methods:
- Systematic review adhering to Meta-analysis of Observational Studies in Epidemiology guidelines.
- Searched MEDLINE, PubMed, EMBASE, and Cochrane databases (1991-2017).
- Keywords included 'recurrent achalasia', 'POEM remyotomy', 'myotomy failure', and 'redo Heller'.
Main Results:
- Included 37 observational studies with data on 289 patients with failed Heller myotomy.
- Treatments comprised pneumatic dilatation (PD) for 87 patients, surgical revision for 166, and peroral endoscopic myotomy (POEM) for 36.
- No randomized controlled trials were identified.
Conclusions:
- Pneumatic dilatation, surgical revision, and POEM are effective and safe for failed achalasia surgery.
- An algorithm-based approach, with procedures performed by experienced teams, can optimize outcomes.
- This review provides a framework for managing recurrent achalasia after initial myotomy.