Persistent and recurrent achalasia after Heller myotomy: analysis of different patterns and long-term results of reoperation.

HYPOTHESIS Two groups of patients with inadequate therapeutic success after surgical treatment for achalasia can be identified, patients with type 1 recurrence (early recurrence after technical failure of myotomy or a scarring process requiring remyotomy) and patients with type 2 recurrence (late recurrence with irreversible progression of the disease and development of megaesophagus requiring esophagectomy). DESIGN Prospective study. SETTING University-based tertiary care center. PATIENTS One hundred sixty-three patients undergoing surgery for achalasia during 20.3 years. INTERVENTIONS Conventional remyotomy for type 1 recurrence (group 1) and esophagectomy (transhiatal or transthoracic) for type 2 recurrence (group 2). MAIN OUTCOME MEASURES Long-term results after reoperation, including Eckardt score, body mass index, reflux esophagitis, manometric lower esophageal sphincter resting pressure, and radiologic maximum diameter of the esophageal body and minimum diameter of the cardia. RESULTS After reoperation, a postoperative Eckardt score of 1 (corresponding to clinical stages 1 to 2) was calculated in 92.3% of group 1 patients and in 80.0% of group 2 patients. In group 1 patients, the maximum diameter of the esophagus decreased to a median value of 25 mm (range, 20-60 mm), while the minimum diameter of the cardiac sphincter increased to a median value of 10.0 mm (range, 5.0-12.0 mm). After surgery, the resting pressure of the lower esophageal sphincter was reduced to a median value of 8.3 mm Hg (range, 4.0-10.0 mm Hg). CONCLUSIONS Reoperation for achalasia yields good long-term symptomatic outcomes, with relief of dysphagia. Subjective, radiographic, and manometric findings after remyotomy duplicate the good results reported for primary open myotomy.