Re-operation after prior esophagomyotomy

Introduction

Achalasia is an esophageal motility disorder characterized by lack of relaxation of the lower esophageal sphincter and failure of peristalsis within the body of the esophagus. Symptoms include dysphagia, regurgitation, chest pain and weight loss. While the precise etiology of achalasia remains elusive, multiple treatment strategies have been proposed for the management of the disease and palliation of its symptoms. Those include botulinum toxin injection, endoscopic pneumatic dilation and surgical or endoscopic myotomy.

Surgical Heller myotomy (HM), open or minimally invasive, through an abdominal or thoracic approach, has been considered the treatment of choice for the disease with reported symptom relief up to 90% in the short term and similar rates over the long term (1-3). Nonetheless, previous studies suggested a recurrence rate of 10–20% (4). This is generally attributed to an incomplete myotomy, which remains the most common cause for early recurrence. Other potential reasons for failure include a twisted, or hypertensive fundoplication, peptic stricture, fibrosis-scarring and/or mega-esophagus development (5). Those patients typically present with symptoms of dysphagia, odynophagia, chest pain and regurgitation (intraesophageal reflux-related to obstruction/failure of relaxation at the gastroesophageal junction). Palliation in the form of pneumatic endoscopic dilatation is a good first step to control the symptoms (6,7). In some patients, gastroesophageal reflux may be a significant issue impacting quality of life, particularly if a fundoplication was not performed during the initial operation.

Re-operation in this second group with reflux as their main complaint, presents less of a challenge, as a redo-myotomy will generally not be required, and such patients will improve with a partial fundoplication. The current review aims to present and discuss current surgical management strategies in the first group, i.e., patients with symptoms related to persistent esophageal obstruction.

Patient evaluation for recurrent symptoms

Early failure after myotomy is usually related to a technical issue such as an incomplete myotomy, or too tight fundoplication. Early failure may also be related to an inappropriate procedure such as a myotomy in a patient with an end-stage sigmoid esophagus who may have benefited from an early decision for esophagectomy. Late failure may be related to factors such as peptic stricture from reflux or progressive esophageal dilation over time. When failure occurs, an accurate history, assessing symptoms such as dysphagia, chest pain, regurgitation, responsiveness to anti-reflux medications, and symptom duration will be helpful to guide management. A barium swallow and/or endoscopy are good initial investigations. Other studies that are helpful to guide therapy include manometry, computed tomography (CT) scan, gastric emptying study, and Endoflip (8).

Re-do HM

In patients with a failed initial HM, multiple studies have examined and reported outcomes of re-operation (5). Those studies typically recommend a myotomy at a different location (although this may be difficult to determine if the operation was performed several years prior by another surgeon), reversing an existing fundoplication, when present, lysing adhesions circumferentially to free the esophagus, straightening down the esophagus, approximating the hiatus, and if needed, a re-do fundoplication (4,5). These operations can be very challenging. We find that on-table endoscopy is helpful to guage the extent of myotomy, as well as to evaluate for any perforation that may have occurred during the dissection.

Studies examining re-operative HM have demonstrated acceptable outcomes in the appropriate patient population compared to initial HM (Table 1). For instance, Capovilla et al. reported on 49 patients who underwent laparoscopic re-operation after failing an initial laparoscopic Heller myotomy (LHM), a new myotomy was created on the right lateral wall of the esophago-gastric junction in most patients (83.7%) (4). The majority (73.5%) underwent an anti-reflux procedure, most being a Dor fundoplication. The group reported an overall success rate of 81.6% at a median 5-year follow-up (4). Stage IV disease (sigmoid megaesophagus) was the only statistically significant variable associated with higher likelihood of recurrence on multivariate analysis. In a recent case control study by Santes et al., the authors examined a cohort of 70 patients, 35 LHM vs. 35 re-do LHM with a median follow-up duration of 24 (range, 24–48) vs. 34 (range, 17–53) months (5). The authors reported similar Eckardt and integrated relaxation pressure scores between both groups and an overall success rate of 82.1%. The study also reported 71.4% of those patients to have had failure secondary to incomplete myotomy, mainly at the gastric end of the myotomy.

A systematic review by Fernandez-Ananin et al. examined 37 studies including a total of 289 patients with a failed previous myotomy (10). One hundred and sixty-six patients underwent a re-do HM at a mean time of 109 (range, 11–384) months between the initial and the re-do procedures. Approximately 64% of the patients examined underwent pneumatic dilation prior to a re-do LHM. The overall success rate was 86%, while the complication rates were approximately 14%. Those included mucosal perforation and pneumothorax.

The above studies have generally reported on a laparoscopic re-operative approach. Other options to consider are a VATS approach (in patients who may have had multiple prior abdominal operations, or who may require a long myotomy of the esophagus) and per oral endoscopic myotomy (POEM), which also has the advantage of avoiding the prior operative field and allows for a longer esophageal myotomy if needed.

POEM following failed surgical myotomy

POEM is being rapidly adopted by many centers as an alternative to LHM. A systematic review by North & Tewari, which suggested similar clinical outcomes when compared to LHM as an initial procedure, although with a higher incidence of gastro-esophageal reflux disease (6). Surprisingly, North & Tewari report a higher incidence of esophageal reflux and associated symptoms in patients undergoing POEM, even with an existing anti-reflux procedure (6).

POEM has also been reported following a failed LHM with a success rate of 81–100% (11-13). In a study of 10 patients who underwent POEM after a failed surgical myotomy, Onimaru et al. demonstrated a significant reduction of lower esophageal sphincter resting pressure (22.1±6.6 vs. 10.9±4.5 mmHg, P<0.01) and a reduction in the Eckardt score (6.5±1.3 vs. 1.1±1.3, P<0.001) at 3-month follow-up (14). A systematic review by Fernandez-Ananin et al. examined outcomes of 36 patients undergoing a POEM procedure from a total of 289 patients with failed LHM (10). Of those, 80% had underwent pneumatic dilation prior to consideration for endoscopic myotomy. Complications occurred in 14 patients (38%) and included mucosal perforation, subcutaneous and mediastinal emphysema, pneumothorax and pneumoperitoneum. The authors suggest that POEM might be best suited in patients who failed a prior myotomy although had a surgical fundoplication done as a part of their initial procedure, as that would circumvent the major drawback of POEM, which is reflux. While the review reports a success rate of 98.4%, the data is hampered by a short follow-up duration of 7.4 (range, 3–10) months.

In a multi-institutional study by Ngamruengphong et al., the authors reported on 180 patients, half of whom underwent POEM following HM (n=90) and compared outcomes to those without prior HM (n=90) (15). The overall technical success rate in performing endoscopic myotomy in patients with prior HM was 98% compared to 100% in the non-HM group. Relief (Eckardt score ≤3) was reported as 81% compared to 94% in the non-HM group (P=0.01) although with no major difference in adverse events (8% vs. 13%, P=0.23) (15). Post-POEM reflux symptoms appears to have been similar between both groups (30% in prior HM vs. 32% in non-HM group, P=0.85) with most patients (85%) undergoing a fundoplication. Interestengly, prior HM was associated independently with clinical failure after POEM on multivariable analysis [adjusted odds ratio (OR) =3.02; 95% confidence interval (CI): 1.02–8.92; P=0.04]. A systematic review by Kamal et al. published in 2021 reported similar technical and clinical findings, with an overall clinical success rate for POEM after failed HM of 87% (range, 81–91%) (16). Major adverse events, defined as those that required intervention or determined to be moderate or severe according to the American Society for Gastrointestinal Endoscopy (ASGE) lexicon system or as described in the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) white paper, occurred in 5% of the included patients with no cases of esophageal perforation (16). While not the main focus of the review, the authors reported no differences in clinical success, adverse events, post-treatment GERD and esophagitis between patients with and without previous HM (16).

As POEM becomes increasingly performed, additional studies comparing re-do LHM to endoscopic myotomy become paramount. Akimoto performed a retrospective study reporting a single institution experience from Japan comparing outcomes between re-do LHM and POEM procedure in 25 patients (17). The authors concluded that POEM was associated with better surgical outcomes, defined as less operative time, lower blood loss and less intra-operative complications. Complications included esophageal and gastric mucosal injuries and iatrogenic pneumothorax in the surgical cohort. POEM was associated with higher reflux esophagitis after an observation period of 3 months (57% vs. 9%, P=0.033) (17). Currently, it is unclear which approach is optimal after a failed LHM as large, randomized studies remain lacking. An advantage of a laparoscopic approach is that a fundoplication can be taken down if this is felt to be significantly contributing to dysphagia after prior myotomy. The advantage of a POEM is that it avoids the risks of a re-do laparoscopic operation. Our preference with POEM after HM, is to perform a posterior myotomy, as it is likely the previous myotomy was performed on the anterior aspect of the esophagus. Ultimately, the decision on which procedure to select would be based on discussion with the patient and the treatment team, with consideration to the patient’s surgical history, underlying medical comorbidities, surgeon’s comfort in performing either procedures.

Conclusions

To summarize, the data on the best approach to rectify a failed myotomy remains mixed. While LHM remains the gold standard, emerging reports suggest that POEM can be a valid alternative. Further studies are required to further elucidate an algorithmic approach to patients with achalasia that failed a previous myotomy.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Raul Caso and John F. Lazar) for the series “Challenging Robotic Foregut and Diaphragm Procedures” published in the Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-8/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-8/coif). The series “Challenging Robotic Foregut and Diaphragm Procedures” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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