title: Laparoscopic re-operation for failed Heller myotomy.
abstract: Laparoscopic Heller myotomy for achalasia has a 10-20% failure rate and may require re-operation to control persistent or recurrent symptoms. We report follow-up of 15 patients who underwent laparoscopic re-operation for failed Heller myotomy. Between 1993 and 2004, 15 patients underwent laparoscopic re-operation for failed Heller myotomy at our center. The mean duration between procedures was 23 months. Follow-up was completed at a mean duration of 30 months in 14 patients (93%) via a telephone questionnaire. Our overall failure rate for primary surgery (n = 106) was 5.6%. The mechanisms of failure were incomplete myotomy (33%), myotomy fibrosis (27%), fundoplication disruption (13%), too tight fundoplication (7%) and a combination of myotomy fibrosis and incomplete myotomy (20%). Significant symptom improvement was observed with postoperative symptom resolution seen in 71% of patients with dysphagia, 89% for regurgitation, 58% for heartburn and 40% for chest pain. Fifty percent reported excellent results and 79% would recommend the procedure to a friend. Subsequent dilations were performed in four patients (29%). Two patients required conversion to open surgery (13%). Three patients (20%) failed the re-operation and required further revisional surgery. Complications included intraoperative perforation in three (none of which resulted in postoperative morbidity) and a pneumothorax in one patient. Prior endoscopic therapies (pneumatic dilation or Botulinum toxin) were not associated with poor results. Laparoscopic re-operation for failed Heller myotomy is feasible and results are encouraging.
authors.affiliation: Department of Surgery, Creighton University, Omaha, Nebraska 68131, USA.
authors.forename: A
authors.initials: A
authors.lastname: Iqbal
authors.forename: B
authors.initials: B
authors.lastname: Tierney
authors.forename: M
authors.initials: M
authors.lastname: Haider
authors.forename: V K
authors.initials: VK
authors.lastname: Salinas
authors.forename: A
authors.initials: A
authors.lastname: Karu
authors.forename: K K
authors.initials: KK
authors.lastname: Turaga
authors.forename: S K
authors.initials: SK
authors.lastname: Mittal
authors.forename: C J
authors.initials: CJ
authors.lastname: Filipi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004931:Esophageal Achalasia / Q000601:surgery*; D015155:Esophageal Spasm, Diffuse / Q000601:surgery; D049630:Esophageal Sphincter, Lower / Q000503:physiopathology; D005260:Female; D018662:Fundoplication / Q000379:methods; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D017060:Patient Satisfaction; D012086:Reoperation; D017211:Treatment Failure