title: Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia.
abstract: OBJECTIVE
  To assess the causes of failure of laparoscopic Heller myotomy and to verify whether endoscopic pneumatic dilation is a feasible treatment.
  
  
  BACKGROUND
  Laparoscopic Heller myotomy has proved an effective treatment for esophageal achalasia, with good or excellent results in 90% of patients. The treatment of failures remains controversial, however.
  
  
  METHODS
  From 1992 to 1999, 113 patients underwent laparoscopic Heller myotomy for esophageal achalasia. Ten patients (8.7%) reported dysphagia (n = 7) or chest pain (n = 3) a median of 5 months after surgery (range 1-12) and were considered surgical failures. Pre- and postoperative radiologic, manometric, and 24-hour pH monitoring findings in patients with achalasia recurrence were compared with those of 74 asymptomatic subjects.
  
  
  RESULTS
  The preoperative characteristics of the two groups were comparable. After surgery, a decrease in resting lower esophageal sphincter pressure was observed in both groups, whereas the abdominal and overall lengths were significantly shorter among the asymptomatic patients. No patients with recurrence had abnormal gastroesophageal reflux. Based on time to recurrence and manometric and fluoroscopic findings, the etiology of the recurrences was classified as incomplete myotomy upward (n = 1), incomplete myotomy or sclerosis of the myotomy downward (n = 7), or sigmoid megaesophagus (n = 1); in one patient the authors could not establish the etiology. Seven of nine patients were effectively treated with endoscopic pneumatic dilations (median 2 dilations, range 1-4); one refused to undergo further treatment. Two patients underwent redo surgery.
  
  
  CONCLUSIONS
  Recurrence of symptoms after myotomy is mainly related to incomplete myotomy or sclerosis of the distal site of the myotomy; it can be treated by dilations after surgery.
authors.affiliation: Department of Medical and Surgical Sciences, Clinica Chirurgica IV, University of Padova School of Medicine, Padova, Italy. giovanni.zaninotto@unipd.it
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.forename: Mario
authors.initials: M
authors.lastname: Costantini
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Portale
authors.forename: Giorgio
authors.initials: G
authors.lastname: Battaglia
authors.forename: Daniela
authors.initials: D
authors.lastname: Molena
authors.forename: Alessanda
authors.initials: A
authors.lastname: Carta
authors.forename: Michela
authors.initials: M
authors.lastname: Costantino
authors.forename: Loredana
authors.initials: L
authors.lastname: Nicoletti
authors.forename: Ermanno
authors.initials: E
authors.lastname: Ancona
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002404:Catheterization; D003680:Deglutition Disorders / Q000209:etiology / Q000628:therapy*; D004931:Esophageal Achalasia / Q000601:surgery*; D016629:Esophagectomy; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011183:Postoperative Complications / Q000628:therapy*; D017211:Treatment Failure