What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: A systematic review

Abstract

Background:Surgical treatment of achalasia fails in 10%–20% of patients. The most frequent responsible cause is the performance of an incomplete myotomy at primary surgery. The treatment when the failure happens is not well defined. In this study, we review and evaluate the possible treatments to be carried out when surgical myotomy fails. We define its benefits and results, with the purpose of defining a therapeutic algorithm.Materials and Methods:The systematic review was performed following the guidelines established by the Meta-analysis of Observational Studies in Epidemiology statement. We searched several electronic databases (MEDLINE, PubMED, EMBASE and Cochrane) from January 1991 to March 2017, with the keywords 'recurrent achalasia' 'POEM remyotomy', 'esophagomyotomy failure', 'Heller myotomy failure', 'myotomy failure', 'pneumatic balloon dilatation achalasia' and combinations between them, 'redo Heller', 'redo myotomy', 'reoperative Heller'.Results:A total of 61 observational studies related to the treatment of patients with failure of Heller's myotomy were initially found. Finally, 37 articles were included in our study that provided data on 289 patients. Of these 289 patients, diagnosed of failed Heller's myotomy, 87 were treated with pneumatic dilatation (PD), 166 underwent surgical revision and finally 36 were treated with POEM. No randomised controlled trial was identified.Conclusions:The three therapeutic options analysed in this review are effective and safe in the treatment of patients with achalasia with failure of surgical myotomy. The best results can be achieved following an algorithm similar to the one proposed here, where each procedure must be performed by well-experienced team in the selected modality.

First splenic rupture following an endoscopic esophageal myotomy: A case report

“…Since its development, POEM is considered as an efficient procedure in the treatment of achalasia[ 1 ]. It has also evolved as a therapeutic modality in cases of achalasia recurrence after a surgical approach[ 10 ].…”

“…Thousands of cases have been reported and audited[ 2 ]. Cases of repeated POEM, after either endoscopic or surgical procedures, have been reported and evaluated[ 10 ]. Not even a single case of splenic rupture has been reported, reflecting the safety of POEM but this adverse event deserves consideration when more procedures will be done in the future by this approach.…”

<p>Peroral Endoscopic Myotomy as a Novel Treatment for Achalasia: Patient Selection and Perspectives</p>

“…In a meta-analysis. 43 POEM was successful in 98% of patients with prior failed LHM. Another study suggested that POEM had lower operative time and shorter length of stay over redo-LHM in patients with failed prior LHM.…”

Peroral endoscopic myotomy in a pediatric patient with refractory achalasia: a case report and review of the literature

“…LHM has high acceptance and has a spread use as a procedure of choice in patients with primary achalasia (4) . However, LHM failure rate is approximately 10-20% and this group of patients presents recurrent or persistent symptoms (5) . There is limited literature about rescue treatments in patients with Heller myotomy failure.…”

“…To these treatment modalities, the most used in pediatric population is still LHM, but despite the efficacy of this procedure, 10-20% of patients have persistent or recurrent symptoms because of incomplete myotomy, and less frequently because of tight fundoplication or peptic stricture (5) . In these cases, patients are left with few choices to manage their disease, those include BD, redo LHM or a rescue POEM.…”