What to do when Heller myotomy fails: pneumatic dilation, redo Heller, or peroral endoscopic myotomy?

Up to 1 in 5 patients who undergo Heller myotomy will experience a recurrence of symptoms and may require further treatment. There are various reasons that a patient may present with dysphagia after Heller myotomy, which range from an incomplete myotomy to gastroesophageal reflux.

An overview of the available treatment options after a failed myotomy is presented, along with a discussion of outcomes and each technique's advantages and drawbacks.

Contrast studies, endoscopy, and evaluation of esophageal motility can help to provide the correct diagnosis. Pneumatic dilation can be used as a stand-alone treatment or as part of a step-up approach, whereby a redo Heller myotomy or peroral endoscopic myotomy (POEM) is subsequently performed. Redo Heller myotomy is technically challenging, given the nature of reoperative surgery. However, its clinical effectiveness ranges from 69% to 100%. More recently, POEM has emerged as a definitive treatment for patients who have had a failed Heller myotomy. In a randomized trial, POEM was found to be significantly more effective than pneumatic dilation. In patients who have end-stage achalasia or those who have a dilated conduit after an esophagectomy, peroral plication of the esophagus is a novel endoscopic treatment option.

A focus on an accurate patient history and the appropriate use of diagnostic testing can help confirm the correct diagnosis after Heller myotomy. Pneumatic dilation, redo Heller myotomy, and POEM are all effective treatment options for patients with recurrent symptoms due to incomplete myotomy or disease progression.