Surgical management of failed esophagomyotomy (Heller's operation).

An analysis of the causes of failure of Heller's operation is necessary in order to arrive at appropriate treatment. We retrospectively studied 100 reoperations for failed esophagomyotomy. Usually, a repeat myotomy was performed via an abdominal approach if the initial Heller's operation proved a failure, or via a thoracic approach if extensive motor disorders were discovered at manometry. Until 1978, esophagogastric resections were performed for severe esophageal injuries due to reflux after Heller's operation, but since then, duodenal diversion has obviated the need for resection. Antrectomy with Roux-en-Y gastrojejunostomy and vagotomy might be performed via an abdominal approach because the latter, always mandatory, is feasible through a transdiaphragmatic approach. Esophageal resection was reserved for major esophageal asystole, some cases of sclerosis, and carcinomas occurring or discovered after Heller's operation.