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LAPAROSCOPIC REOPERATION IN ACHALASIA PATIENTS WITH FAILED HELLER MYOTOMY. A CASE-CONTROL STUDY.
Oscar Santes^*1, Fernanda Romero-Hernández³, Angélica Rodríguez-Garcés³, Enrique Coss-Adame², Miguel A. Valdovinos², Janette Furuzawa-carballeda⁴, Daniel Azamar-Llamas⁴, Raul Chávez-Fernández⁴, Fidel López-Verdugo⁴, Diego Villela-Franyutti³, Diego Cardeña-Rodríguez³, Gonzalo Torres-Villalobos^1,3
1Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Distrito Federal, Mexico; ²Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, Mexico; ³Experimental Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, Mexico; ⁴Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, Mexico

Introduction: Laparoscopic Heller myotomy (LHM) combined with an antireflux procedure is the treatment of choice in achalasia patients. Persistence/recurrence of symptoms occurs in 10 to 20% of cases. Management of patients after failed LMH is subject of debate (reoperation, POEM, dilation and esophagectomy). Few studies have assessed the efficacy of laparoscopic reoperation (LHM-reop). The aims were a) to identify the reasons of failure, b) to determine if there is an improvement in symptoms and c) to determine effectiveness of the LHM-reop after failed myotomy. Methods: This was a retrospective review of patients who underwent LMH-reop at a third-level hospital during the years 2008 to 2016. Pre-operative clinical data, including GERD-HRQL, EAT (eating assessment tool), Eckardt questionnaires and high-resolution manometry (HRM) were compared with those obtained at postoperative follow-up. Success was defined by an Eckardt < 3. For comparison, we included a control-match group consisting of naïve achalasia patients treated with LHM. Results: Thirty five LHM-reop were performed. LHM-reop and control patients were similar in demographic and clinical parameters. Percentage of patients with postoperative morbidity was higher in the LHM-reop group, but without statistical significance (11.4% vs. 2.8%, p = 0.164) (Table 1). Reasons for previous LHM failure were: incomplete myotomy (60%), fibrosis (25.7%), incorrect diagnosis (11.4%) and structural alterations of fundoplication (2.9%). The mean follow-up was 34 months in the LHM-reop group and 24 months in the control group (p = 0.557). There was a significant improvement when comparing preoperative and postoperative symptoms of each group in all questionnaires (p = <.001). There was no significant difference in symptoms scores after surgery between the LHM-reop and the control group (Eckardt p = 0.063, EAT-10 p = 0.166, GERD-HRQL p = 0.075). Success in the LHM-reop group was 82.1% and 91.4% in controls. Preoperative HRM parameters showed no statistical difference between both groups. In the postperative HRM parameters we did not find statistical difference between the reoperation and control groups (Table 2), but a significant difference was found between the results of preoperative and postoperative HRM parameters for each group (p < 0.001)
Conclusion: LHM-reop in cases of failed LHM has a good viability, efficacy and safety. The results obtained in symptoms control are comparable with the primary surgery. We consider LHM-reop a very good treatment for failed primary LHM and patients should be referred to tertiary care centers for better outcomes.

Table 1. Surgical data

	Reoperation (n=35)	Controls (n=35)	P value
Esophageal myotomy, mean ± SD (cm)	6 cm (5-8)	5 cm (4-6)	.001*
Gastric myotomy, mean ± SD (cm)	3.20 cm (2-4)	2.86 cm (3-5)	.009*
Type of fundoplication Dor (%) Toupet (%)	27 (77.1) 8 (22.9)	18 (51.4) 17 (48.6)	.025*
Surgical time, mean ± SD (min)	233.5 (82.1)	128.9 (19.8)	< .001*
Bleeding, mean ± SD (ml)	56.1 (51.7)	23.2 (12.1)	< .001*
Intraoperative Complications (%)	2 (5.7)	0 (0)	.151
Postoperative Complications (%) Clavien-Dindo II Clavien-Dindo IIIA Clavien-Dindo IIIB	4 (11.4) 1 (2.9) 0 (0) 3(8.5)	1 (2.9) 0 (0) 1 (2.9) 0 (0)	.164
Anesthesia Complications (%)	2(5.7)	0(0)	.151
Hospital stay, mean ± SD (days)	4.2 (3.1)	2.4 (2.4)	<.001*

Table 2. High resolution manometry parameters

	Reoperation group	Control group	P value
IRP preoperative	16.2 ± 16.5	25.7 ± 16	0.854
Basal LES pressure preoperative	24.2 ± 16	34.5 ± 23.8	0.064
IRP postoperative	6.8 ± 5.6	8.3 ± 4.2	0.428
Basal LES pressure postoperative	9.8 ± 7.9	13 ± 6.6	0.293

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