Overview
Definition:
Revisional Heller myotomy refers to a repeat surgical procedure to relieve the lower esophageal sphincter (LES) obstruction in patients who have undergone a previous myotomy for achalasia but have experienced symptom recurrence
Achalasia is a primary esophageal motility disorder characterized by impaired relaxation of the LES and aperistalsis of the esophageal body.
Epidemiology:
Recurrence after an initial myotomy (either open or laparoscopic) ranges from 5% to 30% over time, depending on the initial procedure, surgeon experience, and follow-up duration
Factors contributing to recurrence include incomplete myotomy, LES re-approximation, or esophageal remodeling.
Clinical Significance:
Recurrent achalasia significantly impacts quality of life due to dysphagia, regurgitation, chest pain, and weight loss
Revisional surgery is crucial for symptom control, preventing complications like aspiration pneumonia, malnutrition, and potentially reducing the long-term risk of esophageal cancer, while presenting unique technical challenges compared to primary procedures.
Indications For Revisional Surgery
Symptomatic Recurrence:
Persistent or worsening dysphagia, regurgitation, chest pain, or weight loss after a previous Heller myotomy, confirmed by objective testing.
Objective Evidence:
Manometric evidence of persistent LES hypertension or inadequate relaxation, or radiographic evidence of dilated esophagus with retained food bolus, despite absence of mechanical obstruction.
Failed Non Surgical Management:
Lack of sustained symptom relief with pneumatic dilation or botulinum toxin injections in a patient with prior myotomy.
Diagnostic Approach
History Taking:
Detailed history of initial achalasia symptoms, prior surgical procedure (date, surgeon, technique), post-operative course, and current recurrent symptoms including severity, timeline, and impact on quality of life
Inquire about prior endoscopic dilations or botulinum toxin injections.
Physical Examination:
General assessment for nutritional status
Focus on signs of aspiration (e.g., recurrent cough, hoarseness) or complications from previous surgery
Abdominal examination to assess for prior surgical scars or hernias.
Investigations:
Esophagogastroduodenoscopy (EGD) to rule out mechanical obstruction (stricture, tumor) and assess for esophagitis or Barrett's esophagus
Esophageal manometry (high-resolution manometry preferred) to confirm achalasia subtype and LES function
Barium esophagogram to assess esophageal caliber, tortuosity, and retained bolus
Chest X-ray or CT scan to evaluate for aspiration or mediastinal issues.
Differential Diagnosis:
Peptic stricture, eosinophilic esophagitis, esophageal cancer, extrinsic compression, other functional esophageal disorders, or residual fibrosis from initial surgery causing obstruction.
Surgical Management
Preoperative Assessment:
Thorough review of previous operative reports
Discussion with the patient about risks and benefits, including potential for less optimal outcomes compared to primary surgery and possibility of requiring more extensive procedures like esophagectomy.
Approach Selection:
Laparoscopic approach is preferred if feasible, aiming for a complete dissection of the LES
Open surgery may be necessary for extensive adhesions or complex anatomy
Thoracoscopic approach is also an option.
Surgical Technique:
Careful dissection of the esophagus to identify the previous myotomy plane
Division of residual LES fibers, aiming for a full 360-degree myotomy
Careful attention to avoid injury to the vagal nerves and mucosa
Fundoplication (partial anterior or posterior) is typically performed to prevent significant gastroesophageal reflux (GERD), though its role in revisional surgery is debated and may be modified or omitted based on prior anatomy and surgeon preference.
Intraoperative Challenges:
Dense adhesions from previous surgery, scarring, altered anatomy, and friable esophageal tissue can make dissection difficult and increase the risk of mucosal perforation or bleeding.
Postoperative Care And Complications
Postoperative Care:
Close monitoring for vital signs, pain control, fluid balance, and respiratory status
Gradual reintroduction of oral intake, starting with liquids and progressing as tolerated
Prophylactic antibiotics may be used
GERD monitoring is essential.
Early Complications:
Mucosal perforation, bleeding, mediastinitis, pneumonia, leaks from the staple line (if partial gastrectomy or sleeve gastrectomy was done), wound infection.
Late Complications:
Gastroesophageal reflux disease (GERD) is a significant concern, potentially requiring long-term medical management or further intervention
Recurrent symptoms due to incomplete myotomy or scarring
Esophageal dysmotility exacerbation
Weight loss
Dysphagia from adhesions or tight fundoplication.
Prevention Strategies:
Meticulous surgical technique, especially during dissection of adhesions
Complete division of LES fibers
Judicious use of fundoplication to prevent GERD while avoiding exacerbating dysphagia
Aggressive management of post-operative GERD with proton pump inhibitors (PPIs).
Prognosis And Follow Up
Prognosis:
Successful symptom relief is achieved in a majority of patients (60-80%), but outcomes can be more variable than with primary surgery
The risk of GERD is higher
Long-term monitoring is crucial to identify recurrence or GERD.
Factors Affecting Prognosis:
Severity and duration of symptoms prior to revision, technical difficulty of the dissection, surgeon's experience with revisional surgery, development of GERD, and underlying achalasia subtype.
Follow Up:
Regular follow-up with dysphagia scoring, GERD assessment, and potential need for repeat manometry or endoscopy
Patients should be educated on dietary modifications and lifestyle changes
Long-term PPI therapy may be necessary for significant reflux.
Key Points
Exam Focus:
Recurrence rates post-Heller, common causes of failure (incomplete myotomy, GERD), key diagnostic modalities (manometry, EGD), and challenges in revisional surgery
Management of GERD post-myotomy is a high-yield topic.
Clinical Pearls:
Always rule out mechanical obstruction with EGD before proceeding with revisional myotomy
Be prepared for dense adhesions and potential mucosal injury
Modified or omitted fundoplication may be considered in revisional cases to mitigate GERD while balancing the risk of dysphagia
Aggressive GERD management is critical.
Common Mistakes:
Inadequate dissection of the LES, insufficient length of myotomy, failure to identify and manage significant adhesions, and underestimation of the risk and management of GERD post-operatively
Not performing adequate manometry prior to surgery.