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Forum Name: Gastroenterology Topics

Question: Problems following Hellers Myotomy for Achalasia


 achlad37 - Tue Jun 15, 2010 6:57 am

I am a 37 year old fit, active and sane male. A few years ago, I started to have a problem when swallowing with the feeling that food was stuck in my oesophagus. After seeing a gastroenterologist for a gastroscopy, barium meal, and oesophageal manometry, I was diagnosed with achalasia in May 2009. Two weeks later, I had a laporoscopic Hellers Myotomy, and partial fundoplication.

Everything was fine after the operation, and it seemed to be a miracle cure. My swallowing was perfectly normal again and life carried on as normal. I had no acid reflux or any problems. However, in March 2010 I suddenly started feeling as if I had a lump in my throat below my Adam's apple. It felt as if food was stuck there and I wanted to be sick. I also started regurgiting undigested food (but with no stomach acid). I feel pressure in my chest, a lot of bloating and stomach pain (especially just below my sternum) extending round between my shoulder blades.

I returned to my Gastro, and I was given another barium meal. This showed the barium flowing down nicely straight into my stomach, but also refluxing back up again. The radiographer also showed me on the Xray that there was a lump at the bottom of my oesophagus, which he said was a Hiatus Hernia.

2 days later, I returned to the gastro. He said that I have a sliding Hiatus hernia which was inevitable following the Hellers Myotomy. He said that there was nothing that he could do about it, as repairing my diaphragm would mean I would have difficulty swallowing again. He diagnosed the lump in my throat as my cricopharyngeus muscle being irritated by acid reflux. He prescribed me 2x40mg Omprazole per day, and 1x150mg Ranitidine. He said I would have to take these drugs for the rest of my life.

Now first of all, I am unhappy that I have been told that I have considerable discomfort froma Hiatus Herna that nothing can be done about because of my Achalasia and previous operation. Is this really the case?

Secondly, I read that there are various side effects possible from taking PPI drugs long term- including cancer. I asked my gastro about these, but he dismissed me saying there was no problem with them and "millions of people are taking them without any problems". Should I be worried about taking these drugs?

I really don't know what to do now- my life has been completely disrupted by this at the moment. I am off work sick as I feel continually sick and unwell. Anti sickness drugs don't help and in fact the side effects from them make me feel worse. I don't have any energy to do anything. I am fed up of feeling and being sick and I just want to get back to normal and get back to work and the gym again. I would like a second opinion from somebody, but I don't know how to go about it. I feel as if I have been just brushed aside by my consultant- he told me that I should think of my condition in the same way that somebody who has had a broken leg might have to use a walking stick for the rest of their life... ie i should try and ignore it and get on with things. I am not happy with this attitude. My GP isn't interested and I feel as if nobody wants to help me.

I would appreciate any input from you guys on this board if possible.

Many thanks.
 Dr.M.Aroon kamath - Wed Jul 07, 2010 7:55 am

User avatar Hi,
Esophageal achalasia is an uncommon motility disorder characterized by defective peristaltic activity of the esophageal body coupled with impaired relaxation of the lower esophageal sphincter (LES). Surgical treatment aims to relieve dysphagia by abolition of LES pressure. Among the different techniques described, the Heller myotomy followed by an antireflux procedure is most preferred. This achieves excellent long-term relief of dysphagia in almost 90% of patients. The extent of myotomy and whether fundoplication is necessary are debatable issues which i will not discuss in detail here. Evidence suggests that some type of fundoplication would be necessary together with a myotomy.

In recent years, a minimally invasive approach has become the standard of care in many centers.

All current treatments are at best, palliative, as they are aimed at relieving dysphagia and preventing complications related to stasis, but do not restore normal esophageal motility.

Persistent or recurrent symptoms occur in approximately 10% to
20% of operated cases.
Pneumatic balloon dilation, botulinum toxin injections into the LES or 're- do' surgery can be considered for these cases.

Recurrences can be
- early or
- late.

Causes for failed surgery:
a) an inadequate myotomy, as judged by a residual LESP greater than 18mm of Hg, was associated with a significantly higher incidence of postoperative dysphagia. All patients undergoing
postoperative manometry who had no dysphagia had a decrease in resting LES pressure to <6 mm Hg in response to an induced swallow. This is believed to be one cause of 'early' recurrences.

b) megaesophagus: is an advanced form of achalasia and occurs in very long standing cases. This is characterized by dilatation with a large increase in the esophageal diameter(dolicho-megaesophagus), aperistalsis, associated tertiary contractions, an amplitude of contraction of the esophageal body lower than 20mmHg and by incomplete or absent opening of the LES.
Advanced megaesophagus further increases the already existing risk of neoplasia in achalasia.

Treatment of megaesophagus is controversial. Some surgeons recommend a myotomy as initial treatment and reserve esophageal resection for cases who have persistent symptoms. Others favour esophagectomy as the ideal initial
procedure.

c) Multiple prior therapies (before surgery) are associated with a poorer functional outcome.

d) Wrap herniation: "Wrap herniation has now become the most common mechanism of failure requiring redo. Redo fundoplication was successful in 93% of patients, and most could be safely handled laparoscopically".
(http://journals.lww.com/annalsofsurgery ... do_.3.aspx ).

e) late recurrences due to fibrosis following myotomy.

These recurrences can be managed by regular dilation failing which a redo surgery is indicated. Laparoscopic approach is now standard because of the obvious benefits for patients and surgeons. We present our experience in a case of recurrent achalasia, secondary to incomplete myotomy managed laparoscopically by extended myotomy and a floppy anterior fundoplication.

f) amotile vs vigorous forms of achalasia.The odds of failure of surgery were seen in some studies to be greatest among patients with severe preoperative dysphagia and those with the amotile variety of achalasia.

Few reports on reoperations after failed Heller myotomy have been published. Re-do surgery can be done by the conventional "open" laparotomy or by a laparoscopic approach.Some reports speak of good or excellent results following re-do surgery. Rarely, an esophagectomy may become necessary.

In your case, you nave been unfortunate to be among the minority who manifest failures.I am not aware of which of the risk factors for failure were involved in your case. As your symptoms are affecting your quality of life, i suggest that you should look for a surgeon with experience in re-do surgery for failed Heller's myotomy.
Good luck!

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