A third myotomy with peroral endoscopic myotomy after two failed Heller myotomies.

Heller myotomy is the optimal surgical management for achalasia. Recurrent or persistent symptoms after surgical myotomy can occur in approximately 10% of patients [1, 2]. Failed Heller myotomy presents a diagnostic and therapeutic challenge. An inadequate surgical myotomy is the commonest cause of failure. The appropriate treatment for failed surgical myotomy is controversial. Peroral endoscopic myotomy (POEM) is a novel procedure for treatment of achalasia. POEM has been shown to be effective and safe for the treatment of patients in whom prior surgical myotomy has failed. It is unclear which procedure should be utilized in patients with failed double Heller myotomy. We report the case of a 79-year-old man who had type II achalasia despite undergoing transabdominal Heller myotomy with partial posterior fundoplication (May 2007). The therapeutic result of surgery was inadequate and he subsequently underwent transthoracic myotomy and partial division of the diaphragmatic crus (September 2007), followed by two courses (August 2008 and July 2009) of balloon dilation using a 20mm controlled radial expansion balloon. There was a mild improvement in his symptoms (transient 10% benefit at most according to the patient). The patient underwent an extensive work-up, during which an esophagogastroduodenoscopy showed a dilated esophagus with retained secretion and tight lower esophageal sphincter (LES) (▶Fig. 1 a). The retroflexed view showed a sliding hiatal hernia (▶Fig. 1b). Cine esophagram revealed a classic bird’s beak appearance (▶Fig. 1 c). High resolution esophageal manometry (HREM) confirmed type II achalasia. Multiple therapeutic options were discussed with the patient and he opted for POEM. E-Videos