1. Surgical treatment for achalasia fails in 10-20% of patients due to recurrence of symptoms after surgery. 2. The main causes of recurrence after Heller's myotomy are incomplete myotomy at the lower esophageal sphincter and upper esophageal sphincter as well as fibrosis. 3. Treatment options for recurrence include pneumatic dilatation, repeat laparoscopic Heller's myotomy, per oral endoscopic myotomy, botulinum toxin injection, esophagectomy, and laparoscopic esophagogastrostomy.

1. RECURRENCE AFTER HELLER’S
MYOTOMY
DR PRAVIN JOHN
Dr JOHN AC THANAKUMAR
ANURAG HOSPITAL, COIMBATORE.
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Images from Achalasia by PM Fisichella, et al, Brian Katz-SAGES, Internet

2. Surgical treatment for achalasia fails in 10-20% of patients
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ABBREVIATIONS USED:
LES -Lower Esophageal Sphincter
PD -Endoscopic Pneumatic Dilatation
EGJ -Esophageal Gastric Junction
LHM -Laparoscopic Heller’s Myotomy
POEM -Per Oral Endoscopic Myotomy
GERD -Gastro Esophageal Reflux Disease

3. Pathology
Achalasia is a motility disorder due to a lack of relaxation of Lower Esophageal
Sphincter (LES), in association with aperistalsis of the oesophageal body
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4. AIM OF PRIMARY TREATMENT
Aim is to relieve the dysphagia by reducing LES pressure by
• medical
• physical or
• surgical methods
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Primary Achalasia

5. PRIMARY TREATMENT OF ACHALASIA
Medical Measures -
• Calcium channel blockers or nitroglycerine
• Endoscopic botulinum toxin by injection
Mechanical Measures -
• Endoscopic Pneumatic Dilatation (PD)
Surgical Measures -
• Myotomy
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Primary Achalasia

6. SURGICAL MYOTOMY CRITERIA
Considered treatment of choice
85-90% effective in the long run
By Open or Minimal Access Surgery
Important Steps:
Division at Esophago Gastric Junction (EGJ)
Of longitudinal and circular muscles to expose inner mucosa
Upto half the circumference of the esophagus.
Extent of myotomy - at least 6 cm on the esophageal side
Extent of myotomy - at least 1-2 cm on the stomach side.
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Primary Achalasia
In1914 Heller first described a transabdominal extra mucosal cardioplasty
performed onto the anterior and posterior walls of the cardia

7. TYPES OF SURGICAL MYOTOMY
Laparoscopic Heller’s Myotomy (LHM)
Thoracoscopic Myotomy
Open Surgery
Per Oral Endoscopic Myotomy (POEM)
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Primary Achalasia
Left thoracoscopic postion. Thoracoscopic myotomy.

8. RECURRENCE AFTER MYOTOMY
Myotomy failure is failure of surgery and recurrence of symptoms after surgery
They may include:
• Dysphagia
• Chest pain
• Regurgitation
• Cough or
• Asthma
• Weight loss
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9. CAUSES OF FAILURE IN PD
Causes of failure in Pneumatic Dilatation:
1.Incomplete myotomy at the lower end
2.Incomplete myotomy at the upper end
3.Incomplete myotomy at both the ends
4.Fibrosis
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10. CAUSES OF RECURRENCE AFTER LHM
Causes of recurrence after Laparoscopic Heller’s Myotomy
1.Incomplete myotomy at the lower end in majority
2.Incomplete myotomy at the upper end
3.Incomplete myotomy at both the ends
4.Fibrosis
5.Fundal wrap migration
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11. PER ORAL ENDOSCOPIC MYOTOMY (POEM)
Complications include
Mucosal perforation
Subcutaneous emphysema
Mediastinal emphysema
Pneumothorax
Pneumoperitoneum
Gastro esophageal relux (GERD)
Success rate in 98.4%
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12. FUNDOPLICATION
DOR fundoplication which is anterior
Helps as antireflux procedure
Seals micro perforations if any
Covers mucosa and protects from adhesions to left lobe liver, viscera
Repeat surgery when indicated requires careful, tedious dissection
TOUPET fundoplication which is posterior
Effective to protect against GERD
Unfortunately requires the entire mobilisation of lower end of esophagus
Exposed to anterior, the mucosa forms adhesions to liver & viscera
Repeat surgery takes time and care.
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13. MECHANISM OF CE JUNCTION COMPETENCE
1.Pinch cock of crural sling
2. Diaphragm
3.Oblique angle of entry of Eso
4.Cardiac angle (His) and incisuria
5.Oblique sling fibres of diaphragm
6.Mucosal rosette at CE junction
7.Phreno-esophageal membrane
8.Lungs
9.Lower esophageal sphincter
10.Liver tunnel
Many of these anatomical mechanisms are maintained in Dor fundoplication.
Toupet or posterior fundoplication requires mobilisation of the lower end of esophagus and hence
However results in the prevention of GERD may be similar.

14. POST MYOTOMY DYSPHAGIA
Post Myotomy Dysphagia in Achalasia
• Suspect incomplete myotomy mainly lower end
• Cause not due to myotomy- may be a tight fundoplication
• Tight peptic stricture due to GERD - Prevent by PPI
• Neoplasms of esophagus - Especially squamous type, years later
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15. INVESTIAGATIONS FOR
POST MYOTOMY SYMPTOMS
Barium Swallow
Flexible Endoscopy
Manometry
24 hour Esophageal pH-metry
Esophago Gastric Transit Study
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16. POST LHM TREATMENT CHOICES
Following Heller’s Myotomy, choices of treatment include
1.Pneumatic Dilatation
2.Re Laparoscopic Heller’s Myotomy
3.Per Oral Endoscopic Myotomy
4.Botulinum Toxin Injection
5.Esophagectomy - MIS or Open
6.Esophago- Gastrostomy
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17. POST LHM TREATMENT CHOICES
1.PNEUMATIC DILATATION
PD is an out patient procedure
Effective in 90%, falling down to 67% at 3 years
Is the first therapeutic option
Procedure Specifications:
Dilate only after 4 months (to prevent perforation)
Insufflate at lower pressures, only for one minute
Watch intra-procedure mucosa colour for ischaemia
Use balloon- Rigiflex of 35-40mm in diameter
Number of dilatations allowed is 2
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18. POST LHM TREATMENT CHOICES
2.RELAPAROSCOPIC MYOTOMY
Redo laparoscopy and Myotomy
Safe and effective in 86 %
Indicated after PD or Xray Stage I and II with relapse
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REZENDE’S CLASSIFICATION
GRADE I - Esophagus shows difficult emptying & hypotonia, with episodes of
tertiary waves and no dilation.
GRADE II - Contraction of muscles of gastric cardia ( achalasia). Esophagus
shows mild to moderate increase in caliber, tertiary waves are more present.
GRADE III - Esophagus shows evident increase in caliber. The distal portion has
classic ‘bird beak’ sign.Majority of cases with total dyskinesia of esophagus show
violent contractions of circular musculature.
GRADE IV - In addition to above, intense dilatation of esophagus, which rests on
the right phrenic hemidiaphragm. This is referred to as ‘ sigmoid’ / severe
megaesophagus.

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Rezende’s Classification:
Group 1 - Esophageal hypotonia and gastric bubble
Group II - Moderately dilated esophagus and tertiary waves
Group III- Esophageal dilatation & ‘’bird beak sign on cardia
Group IV- Akinesia and dolicomegaesophagus with ‘bird beak’ sign
Radiological findings in Rezende’s classification
Abud et al, Radiol Bras. 2016

21. POST LHM TREATMENT CHOICES
2.RELAPAROSCOPIC MYOTOMY
Procedure Details
Technique of Redo Lap following LHM
Release of adhesions
Undo antireflux valve
Access mediastinal esophagus
A gastric calibration soft tube also may be used
Greater risk of perforation (93%) if earlier fundoplication is done
if mucosa is adherent to left lobe of liver
Avoid old myotomy
Do another myotomy at another site - to right
Myotomy should extend to stomach on the right 3-4 cm below EGJ
Myotomy should extend to esophagus by 6 cm
Intra operative endoscopy for mucosal integrity, adequacy of surgery
Add antireflux procedure
Avoid antireflux procedure in megaesophagus Stage III, IV
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22. POST LHM TREATMENT CHOICES
3.PER ORAL ENDOSCOPIC MYOTOMY
POEM ( 2010 in Humans)
Endoscopy with accessories allows submucosal tunnel to divide circular muscles
In POEM after LHM, enter posterior wall to avoid surgical myotomy
In primary cases, anterior wall myotomy also may be done
Procedure performed in lateral position
Effective in 98 %
Moreso effective if fundoplication has already been done in the first surgery
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23. POST LHM TREATMENT CHOICES
4.BOTULINUM TOXIN
High relapse rate in relapsed cases after surgery
It produces much fibrosis
Possible high chance of post procedure dysphagia due to fibrosis
Hence not really recommended in redo cases, after initial surgery
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24. POST LHM TREATMENT CHOICES
5.ESOPHAGECTOMY
Esophagel replacement and gastro pasty can eliminate fully dysphagia
Particularly useful in megaesophagus ( > 6cm)
Routes Thoracoscopic or Open ( Transhiatal or Trans thoracic)
Main drawback are high morbidity ( 35%) and mortality (5%)
Hence only to be considered-in radiological Stage IV megaesophagus and
-in megaesophagus where less invasion has failed
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25. POST LHM TREATMENT CHOICES
6.Lap ESOPHAGO-GASTROSTOMY
End stage Achalasia
- Failed botulinum toxin injection
- Failed LHM
- Dysphagia
- Losing weight
- Mega esophagus
Options viable are either total esophagectomy or
Lap Esophago- Gastrostomy
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26. 6.Lap ESOPHAGO-GASTROSTOMY
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Post LHM Dysphagia
Intra Operative
Post operative
Brian Katz- SAGES

27. POST LHM TREATMENT CHOICES
6.Lap ESOPHAGO-GASTROSTOMY
Procedure
Brian Katz- SAGES
Laparoscopic adhesiolysis with 5 ports
Upper gastrotomy
Insertion of endo GIA stapler
One blade in esophageal lumen
Another blade in fundal lumen
Watch and confirm by an endoscope from above
Esophago-gastrostomy achieved with the stapler
Close the fundal defect with stapler/ suturing
Post op Barium study
PPI for reflux symptoms to control GERD
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THE END