A 22 years old male patient had achalasia diagnosed 3 years ago by CT chest with oral and iv contrast, barium swallow and manometry He had endoscopic dilatation 4 times with temporary relief followed by lap. Heller cardiomyotomy 2 years ago with improvement of dysphagia for 3 months only. He had open Heller 4 months ago with improvement of dysphagia for 3 months and then he has dysphagia again. Barium swallow repeated 1 week ago showing achalasia.
Incomplete Heller operation is most often the cause of failure. A complete Heller operation needs i) single cut vertical myotomy of the muscle layer from the constriction limit above to jntra-abdominal area close to the GI junction in a single incision without disturbing the surrounding structures, thus avoiding the risk of GI reflux; ii) the muscle layer has to be separated from the underlying mucosa for at least half the circumference. A Heller operation done in this manner has never failed. Multiple operation permanently damages the area with fibrosis. Lifting the esophagus from its bed and holding it on finger makes the operation easier.
I apologize for mistake in writing GI instead of GE - Gastro-Esophageal or Esophagogastric junction. The muscle has to be incised through its entire thickness from upper limit to as close to GE junction as possible in a single linear cut without disturbing the esophageal attachments to diaphragm opening and below and dissect the muscle layer from half circumference of mucous layer which will appear thick and bulging.
In this particular case, repeated esophageal dilations very cautiously would be the best solution.More surgeries may induce more fibrosis and higher incidence of complications.
We may need further work up with this young patient. We have to know if this is a primary achalasia or secondary. For example we have to rule out eosinophilic esophagitis coexistence, by collecting multiple biopsies from the esophageal body and if positive treat relatively. Further, by having the patient undergo high resolution manometry we may clarify if this is a true achalasia or other esophageal dysmotility lesion (jack hammer etc)
If this an achalasia lesion, especially type II, we could provide him endoscopic treatment by performing POEM (per oral endoscopic myotomy). It can be applied even in failed Heller myotomy patients with success, although technically more demanding due to fibrosis development. Comparative studies have established similar effectiveness between Heller myotomy and POEM, at least over the next one or two years. By applying the POEM technique we achieve longer esophageal circular muscle cut ( 12 cm) and may succeed a better and durable result (Echart score reduction).
Is there still a high pressure zone on manometry / high IRP
If so then a further procedure to open the goj (balloon dilatation or POEM) may be a good option.
If the symptoms ate actually due to Oesophageal motility failure and the IRP is low with decent flow on barium a further procedure is unlikely to help and of course has significant risks
POEM or dilatation may be options if on going high pressure zone depsite surgery.
Barium and ogd findings as well as repeat manometry will help the decision
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