Failure after esophagomyotomy for esophageal motor disorders. Causes, prevention, and management

An accurate preoperative diagnosis of an esophageal motor disorder, including its location (the LES, the body of the esophagus, or both), is essential before proceeding with esophagomyotomy. The operative procedure should be performed with careful attention to certain technical details to ensure completeness of the myotomy, to prevent later healing of the myotomy, and to avoid radical cardiomyotomy that might facilitate the subsequent development of GER. Potential hazards are associated with performing a 360 degrees antireflux procedure in the presence of an aperistaltic esophagus. Early operation before the development of megaesophagus is recommended. The excellent results achieved by resection coupled with antrectomy and Roux-en-Y diversion suggest its wider application to patients with one or more previous failed myotomies, particularly patients with stricture and megaesophagus. Long-term surveillance of patients with achalasia is mandatory in view of the known risk of late development of squamous cell carcinoma.