What is the management plan for a patient with achalasia (difficulty swallowing) status post (s/p) fundoplication?

Management of Achalasia in Patients with Prior Fundoplication

For patients with achalasia who have previously undergone fundoplication, Per-Oral Endoscopic Myotomy (POEM) is the preferred treatment approach due to its ability to provide unlimited proximal extension of myotomy to address both the lower esophageal sphincter and any esophageal body spasm.

Diagnostic Evaluation

The management of achalasia in patients with prior fundoplication requires a comprehensive diagnostic workup to understand the mechanism of persistent dysphagia:

• High-resolution manometry (HRM): Gold standard for diagnosis and subtyping of achalasia 1
• Upper GI endoscopy: To assess for mechanical obstruction and evaluate the integrity of the fundoplication 1
• Timed barium esophagram: To evaluate esophageal emptying and confirm outflow obstruction 1
• Functional luminal impedance planimetry (FLIP): To assess esophagogastric junction distensibility 1, 2
• pH studies: To rule out reflux as a contributing factor 1

Treatment Algorithm

First-line Treatment:

• POEM (Per-Oral Endoscopic Myotomy):
  • Preferred for post-fundoplication achalasia, especially Type III 1
  • Allows unlimited proximal extension of myotomy to address spastic segments 2
  • Avoids surgical dissection through previous fundoplication scar tissue

Alternative Options Based on Achalasia Subtype:

1. For Type I and Type II Achalasia:

   • Pneumatic dilation (PD): Consider balloon dilation to 30-40 mm 1
   • Laparoscopic Heller Myotomy (LHM): If POEM is not available, but requires careful surgical planning due to prior fundoplication 1

2. For Type III Achalasia:

   • POEM is strongly preferred due to ability to perform extended myotomy 1, 3

3. For Elderly/High-Risk Patients:

   • Botulinum toxin injection: Lower risk of perforation compared to pneumatic dilation 2
   • Efficacy in 78-89% of patients with immediate improvement 2

Post-Procedure Management

• Immediate post-procedure:

  • Monitor for perforation (pain, breathlessness, fever, tachycardia) 1
  • Consider contrast study if symptoms develop 1
  • Observe for 4-6 hours post-procedure 2

• Dietary recommendations:

  • Begin with clear liquids and advance as tolerated 2
  • Small, frequent meals to reduce aspiration risk 2
  • Avoid foods that trigger symptoms 2

• Medication management:

  • PPI therapy to prevent reflux complications 2
  • Avoid medications that worsen dysmotility (opioids, anticholinergics) 2

Follow-up Care

• Scheduled follow-up at 1 month and 6 months 2
• Repeat timed barium esophagram to assess treatment efficacy 1
• Consider repeat intervention if symptoms recur 2

Special Considerations for Post-Fundoplication Patients

• Concurrent delayed gastric emptying should be evaluated and treated to reduce the need for redilatations 1
• Consider steroid injections (0.5 mL aliquots of triamcinolone 40 mg/mL to four quadrants) before dilatation to reduce frequency of repeat procedures in refractory cases 1
• Needle knife incision may be considered as an alternative to dilatation for anastomotic strictures 1

Potential Complications

• Perforation risk during pneumatic dilation is 2-4% 2
• Post-POEM reflux may require ongoing PPI therapy 1
• Chest pain after dilatation is common, especially in patients with eosinophilic esophagitis 1

Long-term Outcomes

Laparoscopic Heller myotomy with partial fundoplication has shown good long-term results with 84% of patients reporting significant improvement at 5.3 years follow-up 4. However, 25% of patients may require additional therapy including dilation (18%), repeat surgery (5%), or botulinum toxin injection (5%) 4.

For patients with prior fundoplication who develop achalasia, POEM offers the advantage of avoiding surgical dissection through scar tissue while providing effective myotomy of both the LES and esophageal body when needed.