POEM after Toupet Fundoplication for Achalasia

Peter from Houston sent us this question: “I currently have a Toupet fundoplication and the latest testing shows that I have achalasia not allowing food to enter the stomach. Can a POEM be performed to correct the achalasia without disturbing the fundoplication? Therefore, I would still have GERD protection and able to eat normal food”.

Dear Peter,

Either POEM or Heller myotomy can be performed after Toupet fundoplication for newly diagnosed achalasia. The advantages of POEM over traditional laparoscopic Heller myotomy are faster recovery and less pain. Additional benefits of POEM following Toupet fundoplication include avoiding possible scar tissue formation around gastroesophageal junction from previous surgery. You are right, preserving the Toupet fundoplication will prevent acid reflux after POEM.

I am not sure if you had undergone esophageal manometry prior to Toupet fundoplication. At Houston Heartburn and Reflux Center, esophageal manometry is performed prior to any fundoplication mainly to rule out achalasia. In certain cases, achalasia develops many years after fundoplication surgery, and this may be your case.

I should mention that tight approximation of hiatal opening during hiatal hernia surgery may lead to pseudoachalasia. Pseudoachalasia, like achalasia, is associated with progressive dysphagia, dilated esophagus and narrow esophageal outlet. Pseudoachalasia treatment entails enlarging the hiatal opening to alleviate esophageal outflow obstruction.

I recommend thorough pre-op evaluation by an acid reflux specialist including esophageal manometry, upper endoscopy and contrast study to properly diagnose the problem and choose the solution that best fits your particular condition.