Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Via Giustiniani, 2, 35128, Padova, Italy.
J Gastrointest Surg. 2021 Sep;25(9):2208-2217. doi: 10.1007/s11605-021-05041-x. Epub 2021 Jun 7.
Laparoscopic Heller myotomy (HM) has gained acceptance as the gold standard of treatment for achalasia. However, 10-20% of the patients will experience symptom recurrence, thus requiring further treatment including pneumodilations (PD) or revisional surgery. The aim of our study was to assess the long-term outcome of laparoscopic redo HM.
Patients who underwent redo HM at our center between 2000 and 2019 were enrolled. Postoperative outcomes of redo HM patients (redo group) were compared with that of patients who underwent primary laparoscopic HM in the same time span (control group). For the control group, we randomly selected patients matched for age, sex, FU time, Eckardt score (ES), previous PD, and radiological stage. Failure was defined as an Eckardt score > 3 or the need for re-treatment.
Forty-nine patients underwent laparoscopic redo HM after failed primary HM. A new myotomy on the right lateral wall of the EGJ was the procedure of choice in the majority of patients (83.7%). In 36 patients (73.5%) an anti-reflux procedure was deemed necessary. Postoperative outcomes were somewhat less satisfactory, albeit comparable to the control group; the incidence of postoperative GERD was higher in the redo group (p < 0.01). At a median 5-year FU time, a good outcome was obtained in 71.4% of patients in the redo group; further 5 patients (10.2%) obtained a long-term symptom control after complementary PD, thus bringing the overall success rate to 81.6%. Stage IV disease at presentation was independently associated with a poor outcome of revisional LHD (p = 0.003).
This study reports 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 patients with a highly refractory disease. The failure rate, albeit not significantly, and the post-operative reflux are higher than after primary HM. Patients with stage IV disease are at high risk of esophagectomy.
腹腔镜 Heller 肌切开术（HM）已被接受为贲门失弛缓症的金标准治疗方法。然而，10-20%的患者会出现症状复发，因此需要进一步治疗，包括气扩张（PD）或修订手术。我们研究的目的是评估腹腔镜再次 HM 的长期结果。
我们招募了 2000 年至 2019 年期间在我们中心接受再次 HM 的患者。再次 HM 患者的术后结果（再次组）与同一时间段接受原发性腹腔镜 HM 的患者（对照组）进行比较。对于对照组，我们随机选择年龄、性别、FU 时间、Eckardt 评分（ES）、先前 PD 和放射学分期匹配的患者。失败定义为 Eckardt 评分>3 或需要再次治疗。
49 例原发性 HM 失败后行腹腔镜再次 HM。大多数患者选择在食管胃结合部右侧壁进行新的肌切开术（83.7%）。在 36 例患者（73.5%）中，认为需要进行抗反流手术。尽管与对照组相当，但术后结果有些不太令人满意；再次组术后 GERD 的发生率更高（p<0.01）。在中位数 5 年 FU 时间时，再次组有 71.4%的患者获得良好的结果；另外 5 例患者（10.2%）在补充 PD 后获得长期症状控制，从而使总体成功率达到 81.6%。初次就诊时的 IV 期疾病与修订后的 LHD 不良结果独立相关（p=0.003）。
本研究报告了迄今为止最大的腹腔镜再次 HM 病例系列。该手术虽然困难，但在缓解这组难治性疾病患者的症状方面是安全有效的。失败率（尽管不显著）和术后反流较高，与原发性 HM 相比。IV 期疾病患者有很高的食管切除术风险。
