Incomplete Symptom Resolution Following Heller Myotomy for Achalasia

Sherry sent us this question last week: “I have achalasia and has suffered with it for over 19 years. four years ago I had a Heller myotomy which was unsuccessful. I still cannot swallow and I have the worst heartburn. Like your patient above I am 50 years old and a BMI of 35 making me very obese and would be interested in getting a gastric bypass and Heller myotomy for achalasia treatment. Looking forward to hearing from you soon”.

Dear Sherry,

Esophageal motility is a highly-coordinated neuro-muscular process that propels food and the occasional gastric content reflux into the stomach. Achalasia occurs when these contractions are absent or uncoordinated. Patients typically present with worsening dysphagia and heartburn. Heller myotomy is a palliative procedure that opens the lower esophageal sphincter to facilitate food passage from the esophagus into the stomach. Heller myotomy does not reverse esophageal dysmotility but rather prevents the development of a large and dilated esophagus also called megaesophagus. A large and dilated esophagus may require complete resection to alleviate symptoms. Therefore, we recommend early intervention with achalasia patients to prevent the development of megaesophagus.

An early Heller myotomy with Toupet fundoplication has a very good success rate in terms of alleviating dysphagia and heartburn. Failure to improve following Heller myotomy may be secondary to several reasons:

1- Incomplete myotomy
2- Un-resected esophageal diverticulum
3- Gastroparesis
4- Tight or twisted fundoplication
5- Herniated or slipped fundoplication
6- Megaesophagus

A complete and thorough work up must be completed before any redo Heller myotomy. If the cause of failure is not accurately pinpointed revision surgery is not likely to help you. At Houston Heartburn and Reflux Center, we recommend upper endoscopy, esophageal manometry, upper gastrointestinal contrast study, and gastric emptying study prior to revision Heller myotomy. Treatment is tailored according to workup findings. At Houston heartburn and reflux Center, incomplete myotomy is probably the most common reason for incomplete dysphagia resolution following Heller surgery. The myotomy must be properly extended cephalad and at least 3 cm below the gastro-esophageal junction to completely open the gastric inlet. Endoscopic dilation as well as POEM (Per-Oral Endoscopic Myotomy) are additional tools that may be used for treatment of failed Heller myotomy. POEM is particularly useful in type 3 achalasia allowing the surgeon to perform a long esophageal myotomy that is otherwise difficult to achieve using laparoscopy. POEM however in the setting of morbid obesity may result in severe postoperative GERD. Adding Roux-en-Y gastric bypass surgery for achalasia patients in addition to esophageal myotomy has the advantage of alleviating excess weight and GERD related symptoms.