Background:
Heller’s Myotomy and Per Oral Endoscopic Myotomy carry 10-20% symptoms recurrence incidence. This is thought to be related to either incomplete myotomy or progression of disease. Either Pneumatic Dilatation or repeat myotomy is utilised in the management of these patients. This study aims to present both options, their outcomes, predictors of success and outcomes.
Methods:
Systematic review of (MEDLINE, PubMED, EMBASE and Cochrane) databases from Jan 1990 till current. The study followed the PRISMA guidelines in establishing systematic reviews. The keywords utilised were (Redo myotomy, Redo POEM, Redo Heller’s myotomy, Repeat Cardiomyotomy, Pneumatic Dilatation in Achalasia, Recurrent Achalasia). Studies qualities were assessed according to Newcastle Ottawa Scale.
Results:
A total of 26 studies included, 17 studies (282 patients) related to revisional endoscopic or surgical therapy following failed myotomy, and 9 studies (277 patients) related to pneumatic dilatation following failed myotomy were found. All studies were retrospective except for one RCT and another prospective non-randomised study. 5 studies examined POEM only as revisional method, 4 studies examined LHM as the only revisional method whilst 5 other studies examined both interventions efficacy in revisions. Pneumatic dilatations were directly compared to repeat myotomy in 2 studies.
Conclusion:
This is the largest systematic review for post myotomy recurrence management. PD success rate ranged between 50-95%, whilst repeat myotomy is reported to be 63-100% across multiple studies. Studies reporting Eckardt score describe significant reduction in average scores across the three interventions (PD, redo POEM and redo LHM). Interventions should be tailored according to patients’ manometric, radiological appearance of recurrence and the institutional skills available to achieve best results for this subset of patients.