title: Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation.
abstract: OBJECTIVE
  Two groups of patients with inadequate therapeutic success after surgical treatment for achalasia can be identified, patients with type 1 recurrence (early recurrence after technical failure of myotomy or a scarring process requiring remyotomy) and patients with type 2 recurrence (late recurrence with irreversible progression of the disease and development of megaesophagus requiring esophagectomy).
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  University-based tertiary care center.
  
  
  METHODS
  One hundred sixty-three patients undergoing surgery for achalasia during 20.3 years.
  
  
  METHODS
  Conventional remyotomy for type 1 recurrence (group 1) and esophagectomy (transhiatal or transthoracic) for type 2 recurrence (group 2).
  
  
  METHODS
  Long-term results after reoperation, including Eckardt score, body mass index, reflux esophagitis, manometric lower esophageal sphincter resting pressure, and radiologic maximum diameter of the esophageal body and minimum diameter of the cardia.
  
  
  RESULTS
  After reoperation, a postoperative Eckardt score of 1 (corresponding to clinical stages 1 to 2) was calculated in 92.3% of group 1 patients and in 80.0% of group 2 patients. In group 1 patients, the maximum diameter of the esophagus decreased to a median value of 25 mm (range, 20-60 mm), while the minimum diameter of the cardiac sphincter increased to a median value of 10.0 mm (range, 5.0-12.0 mm). After surgery, the resting pressure of the lower esophageal sphincter was reduced to a median value of 8.3 mm Hg (range, 4.0-10.0 mm Hg).
  
  
  CONCLUSIONS
  Reoperation for achalasia yields good long-term symptomatic outcomes, with relief of dysphagia. Subjective, radiographic, and manometric findings after remyotomy duplicate the good results reported for primary open myotomy.
authors.affiliation: Department of General and Abdominal Surgery, Johannes Gutenberg University of Mainz, Mainz, Germany. gockel@ach.klinik.uni-mainz.de
authors.forename: Ines
authors.initials: I
authors.lastname: Gockel
authors.forename: Theodor
authors.initials: T
authors.lastname: Junginger
authors.forename: Volker F
authors.initials: VF
authors.lastname: Eckardt
mesh_terms: D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures; D004931:Esophageal Achalasia / Q000145:classification / Q000601:surgery*; D016629:Esophagectomy; D004944:Esophagoplasty; D004947:Esophagus / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012008:Recurrence; D012086:Reoperation; D017211:Treatment Failure; D016896:Treatment Outcome