Blown-out myotomy: an adverse event of laparoscopic Heller myotomy and peroral endoscopic myotomy for achalasia

Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia

“…The Eckardt score and the integrated relaxation pressure are greater in these patients, and type 3 achalasia and HM seem to be the main factors predisposing to a “ballooning” myotomy. 14 Overall, we found a pseudodiverticulum in 2 (7.7%) patients. It may be speculated that a posterior and long myotomy possibly sparing the longitudinal muscle layer, which is feasible using POEM, may prevent the occurrence of a symptomatic pseudodiverticulum requiring revision and stapled resection.…”

Pseudodiverticulum at the myotomy site in achalasia: Significant finding or overblown?

“…Although the authors hypothesized that this area could act as an area of stasis, symptoms were not experienced by their cohort. In this current study, Triggs et al 5 revisit this phenomenon of pseudodiverticulum formation at the myotomy site in a retrospective review of 129 patients with achalasia. These patients received a surgical (n Z 65) or an endoscopic (n Z 64) myotomy.…”

“…The term "BOM" appears to highlight the hypothesis that residual muscle contraction in the esophageal body leads to the formation of this pseudodiverticulum over time, which appears unlikely to be the sole explanation on the basis of earlier data, where the timing between the myotomy and radiologic assessment was <30 days. The main findings of the study 5 were that (1) "distal esophageal ballooning" or "BOM" was associated with treatment failure in achalasia defined by an elevated Eckhart score, that (2) "BOM" occurs more frequently after Heller myotomy compared with POEM, and (3) "BOM" occurs more often in achalasia subtypes 2 and 3. The authors argue that BOM may be an important mechanism by which treatment failure in achalasia occurs despite adequate myotomy, even though in their own data the median integrated residual pressure (IRP) in patients with BOM was significantly higher than in those without (15.0 mm Hg vs 11.0 mm Hg).…”

“…This does not rule out that stasis of solid food and residual contractility in patients with type 2 and type 3 achalasia may further contribute to a poor clinical outcome over time, but clearly the pathophysiology of treatment failure in achalasia remains incompletely understood, and an elevated IRP may potentially play a significant role, producing symptoms of treatment failure among patients with achalasia. We do not yet fully grasp the pressure dynamics that lead to relapse of achalasia, but the authors nicely speculate this in Figure 3 of the article, 5 depicting an esophagus that gradually evolves from acting more like a common cavity with the stomach to eventually becoming "blown out" and not emptying.…”

“…Overall, the study by Triggs et al 5 represents a step in the right direction for exploring factors that might be important and modifiable among patients with treatment failure after myotomy. Similar to many previous retrospective studies, it has generated rich hypothesisgenerating data that will help shape future studies.…”