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PS01.012: LAPAROSCOPIC REMEDIAL MYOTOMY FOR RECURRENT ESOPHAGEAL ACHALASIA


 
 
 Revisional surgery is sometimes necessary after failed laparoscopic Heller myotomy for esophageal achalasia. We evaluated the feasibility complications and final outcome of laparoscopic revisional myotomy (LRM) for recurrent esophageal achalasia.
 
 
 
 Post-operative outcome after LRM at our Institution between 2000 and 2017 was assessed by a symptom questionnaire, endoscopy, barium swallow and pH-monitoring.
 
 
 
 Forty-one patients underwent LRM: 7 from our series, 34 from elsewhere. Primary treatments included laparoscopic (20 pts) or open (5) Heller-Dor; laparoscopic (6) or open (7) Heller-Nissen; 3 pts had open myotomy only. Thirty-four pts (83%) underwent a median of 3 (1–6) pneumatic dilations (PD) between primary operation and LRM. All the operations were performed laparoscopically. The median operating time was 180 minutes (65–260). One patient was converted to open for a mucosal lesion. The fundoplication was dismounted, when present. A new myotomy, longer than the previous one (especially on the gastric side), was performed in a healthy tissue, on a different quadrant of the esophageal wall. A fundoplication was reconstructed in 29 patients (70.7%) by performing a Dor (24 pts) or a Toupet (5) procedure. Two patients needed laparoscopic revision on 2nd post-operative day (POD) for radiological evidence of an obstructive fundoplication. One patient required revision on 2nd POD for a leakage, treated by suture and conversion from a Toupet to a Dor. Median follow-up time was 76 months (2–179). After revisional surgery, 27 pts had a resolution of their symptoms (66%), whereas other 6 (14.6%) needed further PD to achieve a satisfactory outcome. Other 4 patients (9.8%) still need periodic PD and 3 patients (7.3%) required esophageal resection. Endoscopic gastrostomy was necessary in one patient (2.4%) who wasn’t suitable for resection. Reflux was detected in 11 patients (26.8%).
 
 
 
 LRM is feasible when primary surgery has failed. One-third of the patients still require repeat dilations or esophagectomy, especially in case of megaesophagus. Albeit this is a more difficult operation and carries significant morbidity, LRM may provide the resolution of symptoms to an overall 80% of this group of patients, highly refractory to standard treatments.
 
 
 
 All authors have declared no conflicts of interest.
