Management of recurrert symptoms after esophagomyotomy for achalasia

From 1967 to 1989, we treated 79 patients with recurrent esophageal symptoms after one or more Heller's procedures for achalasia. Dysphagia and/or regurgitation was the predominant symptom in 69 patients (87%), whereas 10 patients (1%) complained mainly of heartburn. Based on clinical assessment, six causes of failure were recognized: 1) inadequate myotomy (n = 37); 2) reflux esophagitis (n = 18); 3) dolichomegaesophagus (n = 13); 4) periesophageal sclerosis (n = 5); 5) hiatal hernia (n = 5); 6) obstructing fundoplication (n = 1). Fifty-one patients required surgery, 27 received endoscopic treatment, and one medical treatment only. There was no mortality. The overall success rate of surgical and endoscopic treatment was 85.7% and 76.2% respectively. Two patients required further surgical treatment, and four were reoperated on after an unsuccessful attempt at dilatation. We conclude that reoperation after failed esophagomyotomy is safe and effective in selected patients. Pneumatic dilatation is a reasonable therapeutic option in patients with mild dysphagia or inoperable because of a high surgical risk.