Persistent or Recurrent Symptoms After Heller Myotomy for Achalasia: Evaluation and Treatment

Esophageal achalasia is a primary esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter in response to swallowing and absent esophageal peristalsis. The treatment is palliative, and it is directed toward elimination of the functional obstruction caused by the non-relaxing lower esophageal sphincter. Pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic myotomy with a partial fundoplication are the available treatment modalities, and they all have a very high initial success rate. Unfortunately, because treatment is palliative, a large percentage of patients will eventually experience recurrence of symptoms during their lifetime, requiring additional treatment. In these patients, it is important to perform a careful workup to identify the cause of the failure and to design a tailored treatment plan by either endoscopic means or revisional surgery. Esophagectomy should be considered an ultimate option. In patients who have failed other treatment modalities and whose quality of life is still negatively affected by the disease, the best results are obtained by a multidisciplinary team approach, in centers where radiologists, gastroenterologists, and surgeons have experience in the diagnosis and treatment of this rare disease.