Redo Laparoscopic Heller's Cardiomyotomy for Recurrent Achalasia: Is Laparoscopic Surgery Feasible?

Introduction

Achalasia cardia is an esophageal motor disorder characterized by increased lower esophageal sphincter (LES) pressure and lack of coordinated LES relaxation in response to swallowing. Objective of the surgical treatment is to relieve dysphagia by decreasing LES pressure. Off late, minimally invasive procedures have become the procedure of choice compared with conventional open surgery. After the primary surgery, recurrence or persistent symptoms have been noted in almost 10%–20% of cases. ¹ There are limited reports published on reoperation for persistent or recurrent symptoms after previous myotomy. In this case series, we share our experience with a series of 7 patients for recurrent symptoms following Heller's myotomy for achalasia cardia who required redo surgery, which was performed laparoscopically.

Materials and Methods

From a period of January 2010 to January 2017, a total of 72 surgeries were performed for achalasia cardia (Laparoscopic Heller's cardiomyotomy combined with antireflux procedure) at our center. Of these surgeries, 7 were performed as redo surgery in previously operated patients for the same. For all the patients with suspected recurrent achalasia, following clinical assessment (mean Eckardt score 6.6 + 1.4), endoscopic assessment was done to rule out mechanical obstruction and assessment of gastric cardia and gastroesophageal (GE) junction. Barium study was done in all the patients and assessment of esophageal emptying and GE junction morphology was made. Diagnosis of achalasia was supported by barium swallow findings, suggesting dilation of the esophagus, a narrow GE junction with “bird-beak” appearance, and poor emptying of barium. All the patients were subjected to esophageal manometric examination on a 16-channel water perfused video system. The manometric finding of incomplete LES relaxation with aperistalsis, increased basal LES pressure with mean of 28.1 mmHg (range 23–39 mmHg), an elevated baseline esophageal body pressure, and simultaneous nonpropagating contractions confirmed the diagnosis of achalasia.

The commonest symptom of recurrence was dysphagia with variable time of presentation. Out of 7 patients, 3 patients developed recurrent dysphagia within first 12 months following first surgery, 2 patients developed recurrent dysphagia within 2 years, 1 patient within 5 years with associated symptoms of regurgitation and vomiting, while 1 patient presented 6.6 years following the first surgical procedure along with symptoms of dysphagia, regurgitation, halitosis, and weight loss. This patient had undergone open Heller's myotomy with Nissen's fundoplication 80 months ago. All the other 6 patients had undergone laparoscopic Heller's myotomy with or without antireflux wrap. Mean duration between the primary and the redo surgery was 17.9 months (range 11–80 months).

All patients had undergone pneumatic balloon dilatation elsewhere before considering redo surgery. Six out of these 7 patients had initial symptomatic relief following pneumatic dilatation, but they redeveloped dysphagia within 3 months post procedure. One patient reported no relief following dilatation. All these patients were reoperated via laparoscopic approach at our institute. Table 1 summarizes the details of patients, type of primary surgery, mechanism of failure, and mean follow-up of the patients.

Results

The preoperative evaluation in all the 7 patients confirmed achalasia cardia on OGD, barium swallow, and esophageal manometry. Patients had undergone pneumatic balloon dilatation with no long-term relief, hence, option of redo surgery was considered. All the seven procedures were completed laparoscopically with mean duration of surgery of 150 minutes (range 120–180 minutes). Intraoperatively, an attempt was made to understand the cause of failure of the first surgical procedure. In 4 patients, it was concluded that incomplete gastric myotomy was the culprit, in other 2 patients, fibrosis at the previous myotomy scar was found to be the reason for the recurrence, and in 1 patient, no definitive cause could be identified.

Of the 7, only 1 patient had intraoperative complication in the form of inadvertent mucosal tear near GE junction, which was primarily repaired and a feeding jejunostomy was performed for enteral nutrition, and patient was kept nil by mouth for 5 days. All the other 6 patients had uneventful intra- and postoperative course. Mean hospital stay of the patients was 3.5 days (range 3–7 days). Mean duration of follow-up was 23.5 months (range 9–36 months). All the patients were symptomatically better. All the cases of redo Heller's myotomy were combined with Dor's fundoplication. Postoperatively at 3 months, all patients underwent manometry which confirmed LES pressure of 7.5 + 1.2 mmHg. Eckardt score decreased from 6.6 + 1.4 to 1.2 + 1.1. All the reoperated patients showed a significant weight gain of 3 kg (3–7 kg) over initial 6 months. Although pH monitoring was not done postoperatively, none of the patients had complained of gastroesophageal reflux disease (GERD), and no patient required proton pump inhibitors for more than 1 month postoperatively. To quantify the GERD symptoms of these patients, gastroesophageal reflux disease-health related quality of life (GERD-HRQL) symptom severity instrument ² was used and the mean score was <2 at the end of 6 months postoperatively.

Discussion

Esophageal achalasia has incidence of 1–6/100,000 persons and seen usually in the third or fourth decade of life.^3,4 With the available spectrum of treatment options, many treatment modalities are offered to the patient. Despite several options available, laparoscopic Heller myotomy combined with antireflux wrap is considered to be the procedure of choice at many centers with success rate of 90%. ⁵ However, some studies show recurrence of symptoms in 20% cases. Some authors report pneumatic balloon dilatation having success in 80% cases, ⁶ while few studies say that only one third of the patients are relieved by pneumatic balloon dilatation. ⁷ Peroral endoscopic myotomy (POEM) is another newer treatment modality for achalasia with good short-term relief of symptoms. ⁸ Onimaru et al. ⁹ treated 10 patients with recurrent dysphagia following Heller myotomy using POEM. There was short-term relief to his patients with mean LES pressure of 10.9 + 4.5 mmHg, 3 months following surgery. ⁹ Although POEM has shown good short-term results, its technique is associated with high incidence of pathologic reflux, and on longer follow-ups, it may show complications of GERD.^10,11 Long-term follow-up is required to validate the efficacy of POEM. Von Renteln et al. ¹² concluded that out of 70 patients who underwent POEM in 5 centers, 82% were in remission at 12 months, and 42% developed esophagitis.

Several studies have shown that LES pressure of <10 mmHg postprocedure has better prognosis and lesser recurrence,^13,14 which is not achieved in most patients post-POEM. Also, higher preoperative LES pressures are independent predictor of successful outcome of laparoscopic myotomy, ¹⁵ and greater reductions in LES pressure are achieved by Heller myotomy.

For a benign condition such as achalasia, esophagectomy is not advocated even in recurrent or persistent symptoms, as it is associated with 2% and 4% mortality even in expert hands.^16,17 Esophagectomy is also associated with high morbidity.

After the primary surgery, recurrence of symptoms have been noted in almost 10%–20% of cases.^1,3 Rate of reoperation is 6.19% following Heller's cardiomyotomy, and only 2.3% of reoperations were done laparoscopically. ¹⁸ It has also been found that recurrent symptoms such as dysphagia following primary surgery recur early within first 3 years if they are secondary to incomplete myotomy or periesophageal scarring. ¹⁹

From a prospective randomized double blind trial conducted by Richards et al. ²⁰ comparing Heller myotomy with Heller myotomy with Dor's fundoplication, it was evident that latter was superior to Heller myotomy alone in terms of development of postoperative GERD.

To conclude, as skillsets of laparoscopic surgeon has increased along with improved visualization and new energy source, laparoscopic redo surgery is increasingly feasible. Although performed very less frequently, revisional laparoscopic Heller myotomy with antireflux procedure is an effective and feasible minimal invasive procedure for the patients in specialized centers with minimal postoperative complications, less duration of hospital stay, and low chances of recurrence.