What is achalasia status post (s/p) fundoplication?

Achalasia Status Post Fundoplication: Diagnosis and Management

Achalasia status post fundoplication refers to a condition where a patient has achalasia that was either missed before fundoplication surgery or developed after fundoplication, resulting in persistent or worsening dysphagia due to the combination of impaired esophageal motility and the mechanical barrier created by the fundoplication. 1

Diagnostic Approach

Key Diagnostic Tests

• High-resolution manometry (HRM): Gold standard for diagnosis and subtyping of achalasia, especially crucial in patients with prior fundoplication 2, 1
• Upper GI endoscopy: Essential to assess mechanical obstruction and evaluate fundoplication integrity 1
• Timed barium esophagram: Evaluates esophageal emptying and confirms outflow obstruction 2, 1
• pH/impedance monitoring: Rules out reflux as a contributing factor and assesses post-fundoplication reflux 2, 1
• Functional Luminal Impedance Planimetry (FLIP): Useful adjunct to confirm and complement HRM findings by measuring esophagogastric junction distensibility 2

Clinical Presentation

• Persistent or worsening dysphagia after fundoplication
• Regurgitation despite anti-reflux surgery
• Chest pain
• Weight loss
• Aspiration symptoms

Understanding the Condition

Achalasia status post fundoplication can occur in two main scenarios:

1. Missed diagnosis: Achalasia was present but undiagnosed before fundoplication was performed for presumed GERD 3
2. Post-surgical development: Achalasia-like symptoms develop after fundoplication due to:
   • Overly tight wrap
   • "Slipped" fundoplication
   • Progression of underlying esophageal motility disorder 3

Management Options

First-Line Treatment

• Per-Oral Endoscopic Myotomy (POEM):
  • Preferred treatment for post-fundoplication achalasia, especially Type III 2, 1
  • Allows unlimited proximal extension of myotomy to address spastic segments 2
  • Avoids surgical dissection through previous fundoplication scar tissue 1
  • Success rates of 89-97% for symptom improvement 2
  • Requires experienced physicians in high-volume centers (20-40 procedures needed for competence) 2

Alternative Treatments

• Pneumatic dilation (PD):

  • Can be considered for Type I and Type II achalasia 1
  • Higher perforation risk in patients with prior fundoplication
  • Success rates of approximately 68% compared to 90% with laparoscopic myotomy 4

• Laparoscopic Heller Myotomy (LHM):

  • Consider if POEM is unavailable 1
  • Requires careful surgical planning due to prior fundoplication 5, 6
  • May include revision of the fundoplication 7
  • Success rates of 90% when combined with appropriate fundoplication 4

Treatment Selection Based on Achalasia Subtype

• Type I and II achalasia: POEM, PD, or LHM are all effective; decision should be based on available expertise and patient factors 2
• Type III achalasia: POEM strongly preferred due to ability to perform extended myotomy 2, 1

Post-Treatment Considerations

Monitoring and Follow-up

• Immediate post-procedure monitoring for complications such as perforation 1
• Acid suppression therapy: Should be strongly considered in all patients after POEM due to increased risk of post-procedure reflux (41-56% abnormal acid exposure) 2
• Follow-up endoscopy and pH monitoring: Recommended 6-12 months after POEM 2
• Long-term surveillance: Regular endoscopic surveillance to monitor for disease progression and complications of GERD 2

Potential Complications

• Post-POEM reflux: Common complication requiring PPI therapy 2
• Persistent dysphagia: May require additional interventions 2
• Esophageal cancer risk: Patients with achalasia have 5-fold higher risk of esophageal cancer 2

Special Considerations

• Comprehensive evaluation for recurrent symptoms: Should include endoscopy, HRM, and timed barium esophagram 2
• Reflux monitoring: pH/impedance monitoring rather than pH monitoring alone for patients with persistent symptoms after anti-reflux surgery 2
• Belching pattern changes: Fundoplication alters belching patterns by reducing gastric belching and increasing supragastric belching 2

Common Pitfalls and Caveats

1. Failure to obtain preoperative manometry: Can result in missed diagnosis of achalasia before fundoplication 3
2. Relying solely on symptoms: One-quarter of patients with post-POEM reflux are asymptomatic; objective testing is essential 2
3. Inadequate follow-up: Long-term surveillance is crucial due to risk of disease progression and esophageal cancer 2
4. Misinterpreting persistent symptoms: Poor correlation between post-operative reflux symptoms and actual gastroesophageal reflux 2

By following this approach, patients with achalasia status post fundoplication can achieve significant improvement in symptoms and quality of life.