In a 32‑year‑old man with type II achalasia, a 25 mm distal esophageal stricture extending to the gastro‑esophageal junction, a small lower esophageal diverticulum, and prior Heller myotomy who achieved only 50 % improvement after per‑oral endoscopic myotomy (POEM), should a repeat laparoscopic Heller myotomy with a partial fundoplication be performed instead of a Nissen fundoplication?

Laparoscopic Heller Myotomy with Partial Fundoplication is Indicated

In this 32-year-old man with incomplete myotomy after POEM, a repeat laparoscopic Heller myotomy with partial fundoplication (Dor or Toupet) is the appropriate next step—not a Nissen fundoplication. The presence of a distal esophageal stricture, lower esophageal diverticulum, and only 50% symptom improvement after POEM indicates inadequate myotomy that requires surgical correction.

Rationale for Repeat Myotomy

The 2024 AGA guidelines explicitly address this scenario: POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy; however, the decision among treatment modalities should be based on shared decision making 1. While POEM is mentioned as an option, the presence of a 25 mm stricture and lower esophageal diverticulum fundamentally changes the clinical picture—these anatomic complications require surgical management that addresses both the incomplete myotomy and the diverticulum.

Why Surgical Approach is Necessary

• The diverticulum requires definitive management: Epiphrenic diverticula associated with achalasia necessitate both diverticulectomy and myotomy to address the underlying outflow obstruction 2, 3. The diverticulum will not resolve with repeat endoscopic myotomy alone.

• Stricture management: A 25 mm stricture extending to the GEJ suggests significant fibrosis and incomplete prior myotomy. Laparoscopic visualization allows direct assessment of the prior myotomy site and extension of the myotomy to adequate length 2.

• Prior surgical history consideration: The 2024 AGA guidelines note that "patient's surgical history, including prior laparoscopic Heller myotomy and/or POEM, should be considered when determining tunnel orientation" 1. In this case with prior Heller myotomy followed by failed POEM, surgical re-exploration provides the best opportunity for complete myotomy.

Partial Fundoplication, NOT Nissen

A partial fundoplication (Dor or Toupet) must be performed—a complete Nissen fundoplication is contraindicated in achalasia patients. Here's why:

• Absent esophageal peristalsis: Type II achalasia patients lack normal esophageal peristalsis. A 360-degree Nissen wrap would create functional obstruction since the esophagus cannot generate the propulsive force needed to overcome a complete wrap 2, 4.

• Standard of care: The literature consistently describes laparoscopic Heller myotomy with partial fundoplication (Dor anterior or Toupet posterior) as the surgical standard 2, 3, 4. A study of 72 achalasia patients specifically used "Heller myotomy and Dor fundoplication" with excellent outcomes 2.

• Reflux prevention without obstruction: Partial fundoplication provides anti-reflux protection (critical given the myotomy destroys the LES mechanism) while allowing food passage in the absence of normal peristalsis.

Surgical Technique Considerations

Addressing the Diverticulum

• Diverticulectomy is mandatory for symptomatic diverticula, particularly those >2-3 cm 2, 3
• Critical technical point: With a ventrally located diverticulum, spare muscular tissue between the staple line and myotomy to prevent dehiscence 5
• Use intraoperative esophagoscopy to guide the procedure 2

Myotomy Specifications

• Extend the myotomy adequately into the esophagus (typically 6-8 cm) and 2-3 cm onto the gastric cardia 2
• The myotomy should be on the opposite side from the prior POEM tunnel if possible to access virgin tissue 1
• Consider intraoperative functional luminal impedance planimetry (FLIP) to confirm adequacy 1

Common Pitfalls to Avoid

1. Do NOT perform a Nissen fundoplication: This will cause dysphagia recurrence due to functional obstruction in the setting of aperistalsis.

2. Do NOT ignore the diverticulum: Treating only the myotomy without addressing the diverticulum will lead to persistent symptoms and potential aspiration risk.

3. Do NOT perform inadequate myotomy length: The 50% improvement after POEM suggests the prior myotomy was too short. Ensure adequate extension both proximally and distally.

4. Do NOT attempt repeat POEM alone: While technically feasible, it does not address the diverticulum or stricture adequately and has higher failure rates in this complex anatomy.

Postoperative Management

• Initiate proton pump inhibitor therapy immediately postoperatively given the high risk of reflux after myotomy 1
• Perform timed barium esophagram at 6-12 weeks to assess emptying
• Long-term surveillance for GERD complications is mandatory 1
• Monitor for symptom recurrence with Eckardt scoring

The surgical plan outlined in the medical report is appropriate and evidence-based for this complex case.