Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy

Recurrent/persistent symptoms of achalasia occur in 10-20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population.

All patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively.

demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes.

A total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance.

There are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.