LAPAROSCOPIC REVISIONAL SURGERY AFTER FAILED HELLER MYOTOMY FOR ESOPHAGEAL ACHALASIA: LONG TERM OUTCOMES AT A SINGLE TERTIARY CENTER
Giovanni Capovilla*1,2, Renato Salvador1,2, Luca Provenzano1,2, Michele Valmasoni1,2, Lucia Moletta1,2, Elisa Sefora Pierobon1,2, Stefano Merigliano1,2, Mario Costantini1,2
1University of Padova, Padova, Italy; 2Department of Surgical, Oncological and Gastroenterological Sciences, Padova, Italy
Background Laparoscopic Heller myotomy (HM) is the gold standard treatment for achalasia, providing symptom relief in more than 80% of the patients (pts) at a long term follow-up (FU). Ten to 20% of the pts will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. Redo surgery after failed HM is a controversial and poorly addressed topic. The aim of our study was to assess the long term outcome of laparoscopic redo HM
Methods Pts who underwent redo HM at our Center between September 2000 and December 2018 were enrolled. Postoperative outcomes of redo HM pts (redo group) was compared with that of pts who underwent primary Laparoscopic HM in the same time span (control group). For the control group we randomly selected pts matched for age, sex, FU time, symptom score (SS), previous PD and radiological stage. In a sub-analysis of the redo group, comparing pts with a favorable and patients with poor outcome, the univariate and multivariate analyses were performed to identify risk factors for failure after redo HM. Failure was defined as a postoperative SS > 10th percentile of the preoperative SS (i.e. > 8) or the need for re-treatment
Results Forty nine pts underwent laparoscopic redo HM after failed primary HM. The demographics and clinical characteristics are reported in Table 1. The redo HM was always approached laparoscopically: only one conversion to open surgery occurred (2%). A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of pts (83.7%). In 36 pts (73.5%) an anti reflux procedure was deemed necessary. No perioperative deaths occurred. Intraoperative perforations occurred in 2 pts (4%). Two pts (4%) required dismantling of the fundoplication on postoperative day 2 due to complete obstruction at the barium transit. Postoperative outcomes were comparable to the control group (table 2); the incidence of postoperative GERD was higher in the redo group (p < 0.01), however. At a median 62-month FU time, a good outcome was obtained in 73.5% of pts in the redo group. Seven (14.3%) pts required further PD. Three pts (6%) required esophagectomy, one patient (2%) needed an endoscopic gastrostomy, one patient underwent additional HM elsewhere (2%), one patient refused further treatrment (2%). At multivariate analysis, the radiological stage IV disease at presentation was the only variable independently associated with a poor outcome (p = 0.003)
Conclusions This study reports one of the largest case series of laparoscopic redo HM to date. The procedure, albeit difficult, is safe and effective in relieving symptoms in this group of pts with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Pts with stage IV disease are at high risk of esophagectomy
Table 1. Demographic and clinical characteristics of the studied population
Table 2. Analysis of postoperative results: redo pts and control group
* Postoperative SS > 8
** confirmed by positive 24 h pH monitoring or 48 h wireless pH monitoring (BRAVOtm), data available for 26 pts in the redo group and 29 pts in the control group
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