This stage of decompensated achalasia is irreversible and cannot be moderated by endoscopic measures or by nonresecting surgical therapy. In these patients, esophagectomy was associated with a low morbidity rate and good long-term symptomatic outcomes and led to the relief of dysphagia.
Although transhiatal resection with gastric tube pull-up was the procedure of choice, which supports the findings reported by Orringer and Stirling 19 and by Devaney et al, 20 the use of colon interposition described by other authors yielded similarly good results.
The therapeutic concept advocated by this study for patients after unsuccessful Heller cardiomyotomy consists of open remyotomy in patients with type 1 early recurrence and esophagectomy in patients with type 2 late recurrence with the manifestation of progressing disease and a sigmoid-shaped esophagus. Reoperation for achalasia yields good long-term symptomatic outcomes, with relief of dysphagia. A reduction of the esophageal sphincter resting pressure to 10 mm Hg or less was achieved in all patients with type 1 recurrence at the time of the final measurement, serving as an indicator of successful long-term outcomes.
Analysis and interpretation of data : Gockel. Drafting of the manuscript : Gockel. Critical revision of the manuscript for important intellectual content : Junginger and Eckardt. Statistical analysis : Gockel. Study supervision : Junginger and Eckardt. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue.
View Large Download. Table 1. Characteristics of Patients With Reoperation for Achalasia a. Clinical Symptoms Before Reoperation a.
Radiologic and Manometric Findings Before Reoperation a. The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up [published online ahead of print January 10, ].
Surg Endosc ;19 3 Gastroenterology ; 6 PubMed Google Scholar. Ellis FH Jr Failure after esophagomyotomy for esophageal motor disorders: causes, prevention, and management. Etiology, diagnosis, and treatment of failures after laparoscopic Heller myotomy for achalasia. Palmer ED Treatment of achalasia when Heller operation has failed.
Perendoscopic injection of botulinum toxin is effective in achalasia after failure of myotomy or pneumatic dilation. Endoscopy ;33 12 PubMed Google Scholar. Hepatogastroenterology ;38 6 PubMed Google Scholar. Surg Endosc ;17 7 Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Save Preferences. Privacy Policy Terms of Use. This Issue. Citations View Metrics.
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We are working closely with our technical teams to resolve the issue as quickly as possible. In the last three the discomfort was as intense as preoperatively. The patient at stage IV was satisfied and refused any further procedure. We were able to dismount the Dor plasty in the two re-operated patients and redo it. All these patients are well at 34 and 16 months after the second procedure. According to the re-operative findings the reason for failure was attributed to progressive inflammatory stricture.
Chest pain and heartburn mean scores did not significantly increase. Significant heartburn appeared in the three above-mentioned patients with endoscopic evidence of grade 1 oesophagitis, which was satisfactorily treated with proton-pump inhibitors. Kaplan—Meier curve for postoperative symptom-free survival. Dysphagia and heartburn present a different pattern with earlier onset of the latter.
Analysis was possible in 20 subjects for a 4-year period; in the earlier period of the study, questionnaires were not available. Internal consistency was higher for general NHP scores at 1 and 4 years 0. Consistency at 1 year was similar to that at 4 years. In both questionnaires physical domains presented a higher consistency than psychosocial ones.
At postoperative assessment both physical and mainly psychosocial domains improved data not shown and remained stable up to 4 years, approximating values scored by a normal population of the same age. Baseline and positive changes in quality of life scores according to the radiological stage.
Mean baseline values white area and 4 years after surgery grey area evaluated by the Nottingham Health Profile and Short-Form Questionnaires. The area limited by the trait line shows the values of the population of the same age. Normal motility in the oesophageal achalasia cannot be restored with the medical or surgical therapies currently available.
The rationale for care is symptomatic treatment by decrement of lower oesophageal sphincter pressure. In the short term, both pneumatic dilation and surgical Heller cardiomyotomy can relieve dysphagia in most patients [1—4]. Dilation or myotomy may very likely facilitate a gastro-esophageal reflux that can be better faced by prophylactic surgical anti-reflux procedure than chronic consumption of proton-pump inhibitors. Heller's oesophagomyotomy relieves dysphagia but does not restore oesophageal peristalsis.
According to this rationale the addition of a too tight fundoplication may jeopardize the relief induced by myotomy and predispose to relapse achalasia. Comparison between series with no fundoplication, partial or total fundoplication presented different results [16—20].
The automatic relationship between myotomy and reflux has been recently denied by Sharp et al. On the contrary, Ponce et al.
Falkenback et al. Oelschlager et al. Finally, Yau et al. In our opinion, partial fundoplication can prevent reflux after myotomy. This procedure represents a good compromise between the need to prevent otherwise inevitable reflux without re-creating an obstacle too important for an aperistaltic oesophagus.
We have experience with the Dor procedure that we associate with an extended myotomy with good long-term results. The difficulty in evaluating the effectiveness of each surgical technique depends also on the subjective criteria of evaluation and mix of symptoms not always correlated with dysphagia or with reflux [16]. Objective data i. The advent of QOL questionnaires gave a more reliable and comparable outcome assessment measure.
On the contrary, the SF questionnaire has recently been used in some small surgical series [17 , 21—23]. Ben-Meir and colleagues [21] evaluated 19 patients 21 months after surgery and found that physical function, bodily pain, vitality, and social function were significantly improved.
Luketich and colleagues [22] studied 53 patients and found that after myotomy, all eight domains of SF data scored at least equal or better than the normal US population used for comparison. However, in this series, no preoperative data were available for pre- to postoperative comparisons.
These results were analogous with those obtained by Ponce et al. Katilius et al. The SF general health domain improved significantly in both groups although best scores in physical function and bodily pain were achieved following laparoscopic myotomy.
Postoperative QOL assessment revealed no difference with the general population. Our findings support the use of the SF as a reliable instrument for QOL assessment in achalasia patients.
We have found greater postoperative improvements in the domains such as role limitations due to physical problems and social function. Correlation with degree of dysphagia and pressure of lower oesophageal sphincter seems not surprising since the existence of symptoms and signs leading to modification of eating habits has also been shown to impair QOL in other benign oesophageal diseases [24].
Findings recently reported by Decker et al. Your physician may do any of the following:. Most patients may take clear liquids the same day after a Heller myotomy. You may begin a soft food diet 2 to 3 days later. Within a month, you may return to a normal diet. If you receive the minimally invasive surgical approach, your hospital stay will be approximately two to three days. You may be able to return to work in two to three weeks.
If you receive the open surgery, you may have to be away from work for at least a month. You may not do any heavy lifting for at least six weeks. If you have achalasia , a Heller myotomy will offer long-term relief, but it will not completely eliminate symptoms.
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