[size=20px]A 15-year old boy returns to the clinic two years following a laparoscopic Heller myotomy with Dor fundoplication for achalasia. Though he had early excellent resolution of his symptoms he now has dysphagia and recent weight loss. An esophagram suggests recurrence of the distal narrowing with moderate obstruction and manometry confirms recurrent achalasia.

 

The procedure most associated with long term success in this patient with recurrent achalasia is

 

A revision Heller myotomy.

 

B esophagoscopy and botulinum toxin injection.

 

C esophagectomy with gastric replacement.

 

D pneumatic balloon dilation.

 

E peroral endoscopic myotomy (POEM).[/size]

A

A

correct

 

Although surgical treatment of achalasia with Heller myotomy has better long term results than initial pneumatic balloon dilation, there is still a substantial incidence of recurrent symptoms after myotomy - ranging from 30 to 50%. When symptoms recur, an attempt at balloon dilation with or without Botox injection is a reasonable option although myotomy revision (either as an extension of the previous myotomy or a new myotomy at a different site) provides the best long term results.

 

Initial operative failure is most often due to inadequate myotomy distally onto the stomach and less commonly to the development of fibrosis of the previous myotomy. Reoperation often needs to focus on performing an adequate distal myotomy onto the gastric fundus. With the evolution of intraluminal approaches to myotomy (i.e. per oral endoscopic myotomy, POEM), there are some small series that report high rates of success with POEM for recurrent achalasia. Esophagectomy should be reserved as a last resort option and botulinum toxin injections alone are recommended for high risk elderly adult patients who might not tolerate more aggressive therapy.