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Andrea Costantini*, Renato Salvador, Luca Provenzano, Giovanni Capovilla, Loredana Nicoletti, Francesca Forattini, Arianna Vittori, Giulia Nezi, Michele Valmasoni, Mario Costantini
Dept. of Surgical, Oncological and Gastroenterological Sciences, Universita degli Studi di Padova Scuola di Medicina e Chirurgia, Padova, Veneto, Italy

Background: In the last 3 decades, laparoscopic Heller myotomy (LHM) has represented the treatment of choice for esophageal achalasia, solving symptoms in most patients. Little is known about the fate of patients who relapsed after surgery, or about their most appropriate treatment. In this study we aimed at evaluating the results of complementary pneumatic dilations (CPD) after ineffective LHM.
Material and methods: We evaluated the patients with esophageal achalasia who underwent LHM plus Dor fundoplication (LHD) from 1992 to 2021 and were submitted to CPD for persistent or recurrent symptoms. An Eckardt score >3 was used as threshold of LHD failure. The patients were followed clinically and with manometry, Barium swallow and endoscopy when necessary. A persistent Eckardt score >3 was considered a failure of the complementary treatment. Continuous data were expressed as medians (IQR), and categorical data as numbers and percentages. Mann–Whitney test, Chi-square test, and Fisher's exact test were used when appropriate.
Results: Out of 1420 patients undergoing LHD in the study period, 115 (8.1%) were considered failures following the above criteria and were offered CPD. Ten patients refused further treatment, in 5 CPD was not indicated for severe reflux esophagitis, 1 patient had surgery for a misshaped fundoplication and 1 last patient developed a cancer 2 years after LHD; that leaves 103 patients who underwent a median 2 CPD (IQR 1-3), at a median of 16 (IQR 8-36) months after surgery, with 3.0 to 4.0 cm Rigiflex dilator. All procedures were performed in an outpatient setting. No perforations were recorded. Only 6 patients were lost to follow up. The remaining 97 were followed for a median of 37 months (IQR 6-112) after the last CPD: 70 (72%) saw their symptoms healed, whereas 27 (28%) still complained of symptoms (Eckardt score >3). The only differences between the 2 groups were the Eckardt score before CPD, that was 3 (IQR 3-4) in the former and 4 (IQR 4-5) in the latter (p<0.05), and the number of required CPD, that was 2 (IQR 1-2) and 3 (IQR 1-3), respectively (p<0.05, Table 1). All other parameters [radiological stage and size of the gullet, manometric subtype, previous endoscopic treatment, the time of recurrence (Figure 1) and duration of symptoms, etc.] were similar between the 2 groups. Of the un-responding patients, 17 still require repeated CPD, 7 eventually underwent re-myotomy, 1 POEM and 1 esophagectomy for end-stage disease. In overall, the combination of LHD + CPD provided a satisfactory outcome in 96.8% of the treated patients.
Conclusion: CPD represent an effective, safe option to treat patients with esophageal achalasia after a failed LHD: when the post-surgery Eckardt score consistently remains high, and the number of CPD exceeds 3, this may suggest the need for further invasive treatments.

Time of symptom recurrence after LHD in patients who eventually responded to CPD treatment and in patients who did not.

A comparison of demographic, clinical, radiological and HR manometric parameters in patients who eventually responded to CPD treatment and in patients who did not after failed LHD,

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