Incomplete myotomy is the most common indication for re-intervention after a sur­gical myotomy, responsible for around 50% of all revisional operations [4]. This should certainly be the rst suspicion when evaluating a patient with recurrent dys­phagia after myotomy and can be related to either inadequate proximal or distal extent of the myotomy. Studies have shown that an extended myotomy at the initial procedure reduces relapse rates from 17% to 5% and the need for re-intervention from 7% to basically 0% [3]. When incomplete myotomy is suspected as the cause of symptoms, surgical extension of the myotomy, either laparoscopically or endo­scopically, is likely to be effective. While this can certainly occur in achalasia if the myotomy is not extended all the way through the high pressure zone, it is particu­larly likely in cases of non-achalasia motility disorders, such as diffuse esophageal spasm (DES) and Jackhammer esophagus that involve the entire esophagus. As the problematic portion of the esophagus may extend well above a traditional LES myotomy, a classic laparoscopic Heller myotomy (LHM) may result in an incom­plete myotomy being performed, simply due to the technical limitations of extend­ing a long myotomy from an abdominal approach. While VATS can be performed to lengthen this dissection, it does add some morbidity. POEM can be more effective in this regard, but incomplete myotomy is still possible if there is missed division of circular bers or incomplete proximal or distal extension due to misidentication of landmarks or measurements.

quality of life scores seem to be fairly similar between the two groups and that most patients with post-myotomy GERD (POEM or LHM) are easily managed with med­ications alone [9]. Reux can also be the cause of dysphagia (due to esophagitis or peptic strictures), in which case aggressive PPI therapy is indicated as rst-line treatment before surgical re-intervention [3]. However, in rare cases, revisional sur­gery may be required if symptoms are severe or if patients have a contraindication to long-term acid suppression medication.

In patients undergoing LHM with fundoplication, wrap failures can cause signi­cant symptoms. A loose or dehisced fundoplication can lead to GERD, as men­tioned above, while a slipped, overly tight, or herniated fundoplication may be associated with dysphagia or pain. Wrap failure is the reason for reoperation in approximately 25% of failed Heller myotomies [7]. In these cases, treatment may need to be focused on the wrap rather than the myotomy.

developed from an intrathoracic myotomy site and could be contributing to symp­toms. UGI may show also the presence of esophageal spasm, which can be a valu­able diagnostic tool, particularly if the patient is symptomatic at the time of the test.

Medical options for failed motility procedures are somewhat limited, though in the setting of mild symptoms or high-risk patients, conservative treatment may be best in some scenarios. If spasm, as evidenced by noncardiac chest pain, is a primary issue, either new or persistent, esophageal relaxants such as calcium channel blockers (Nifedipine) may be effective in a partially myotomized esophagus, even if the patient had incomplete relief with these medications prior to their myotomy. Narcotics should be avoided whenever possible in the case of esophageal pain as they are unlikely to be effective and carry signicant side effects and risks and can actually worsen esopha­geal contraction strength or induce spastic peristalsis [17]. Botox is generally not rec­ommended after a myotomy due to high failure rates and development of brosis [3].

Pneumatic dilation is a good initial treatment choice in patients with recurrent dys­phagia after myotomy, with 64–80% of recurrent patients (whether LHM or POEM) having good results with PD [3]. PD is reported to have a high short-term success rate of approximately 85% after failed Heller but requires a mean of 2.5 treatments (range 1–3) [3]. Presumably, some of this effect would deteriorate over time, as is the case in treatment naive achalasia patients who undergo pneumatic dilation, in whom long-term effectiveness is only around 60% [3]. If pneumatic dilation is to be under- taken after a myotomy, timing is important. The risk of perforation is highest in the rst 4months after surgery, and it should be avoided in this time frame if possible. If early dilation is needed, it can be still acceptable to dilate to 35–40mm, but it should be recognized that there is signicant scar tissue, which will increase the risk of esophageal perforation with more aggressive dilations [3]. After two dilations, if the patient is not improved, it should be considered a treatment failure and surgical revi­sion should be considered. Savary or wire guided dilations are also acceptable but are less effective and should be used with caution in cases of sigmoid esophagus.