Persistent and recurrent achalasia after heller myotomy - Analysis of different patterns and long-term results of reoperation

Hypothesis: Two groups of patients with inadequate therapeutic success after surgical treatment for achalasia can be identified, patients with type I recurrence (early recurrence after technical failure of myotomy or a scarring process requiring remyotomy) and patients with type 2 recurrence (late recurrence with irreversible progression of the disease and development of megaesophagus requiring esophagectomy). Design: Prospective study Setting: University-based tertiary care center Patients: One hundred sixty-three patients undergoing surgery for achalasia during 20.3 years. I nterventions: Conventional remyotomy for type I recurrence (group 1) and esophagectomy (transhiatal or transthoracic) for type 2 recurrence (group 2). Main Outcome Measures: Long-term results after re-operation, including Eckardt score, body mass index, re-flux esophagitis, manometric lower esophageal sphincter resting pressure, and radiologic maximum diameter of the esophageal body and minimum diameter of the cardia. Results: After reoperation, a postoperative Eckardt score of 1 (corresponding to clinical stages 1 to 2) was calculated in 92.3% of group 1 patients and in 80.0% of group 2 patients. In group I patients, the maximum diameter of the esophagus decreased to a median value of 25 mm (range, 20-60 mm), while the minimum diameter of the cardiac sphincter increased to a median value of 10.0 mm (range, 5.0-12.0 mm). After surgery, the resting pressure of the lower esophageal sphincter was reduced to a median value of 8.3 mm Hg (range, 4.0-10.0 mm Hg). Conclusions: Reoperation for achalasia yields good long-term symptomatic outcomes, with relief of dysphagia. Subjective, radiographic, and manometric findings after remyotomy duplicate the good results reported for primary open myotomy.