The initial treatment of these patients should always include a pneumatic balloon dilatation in these patients. Contrary to common belief, the risk of esophageal perforation is very low since the stomach if a Dor fundoplication was performed or the left lateral segment of the liver if a Toupet was added to the myotomy cover the myotomy, or by. Zaninotto et al. reported recurrent dysphagia in 9 of 113 patients (8 %) after LHM and Dor fundoplication [17]. Seven of the nine patients were effectively treated by balloon dilatation (median two dilatations, range 1–4), while a second operation was necessary in two. Similar outcomes were described by Sweet et al. who reported on the effectiveness of dilatation for the treatment of both persistent and recurrent dysphagia [7].

If dysphagia is not relieved by dilatations, a re-operation must be considered. When discussing with the patient the risks and benefits, it is important to stress that even though the laparoscopic approach is feasible in most cases, a laparotomy might be needed. In addition, patients must be aware that in case of severe damage to the mucosa during the course of the operation, an esophagectomy may be necessary.

The first step of the operation consists in separating the liver from the stomach and the esophagus. The fundoplication must be then taken down and the fundus brought to the left in order to expose the esophageal wall. Adequate and complete exposure of the esophageal wall, including a thorough dissection of the previous myotomy is the next step. Once this has been accomplished, it is easier to perform a new myotomy rather than trying to extend the prior myotomy. The new myotomy is performed on the opposite side on an unscarred part of the esophageal wall (Fig. 16.2). The myotomy should be extended for about 3 cm below the GEJ, and intra-operative endoscopy should be performed to evaluate for inadvertent esophageal or gastric mucosal injury. After the myotomy is completed, consideration should be given whether or not to add a fundoplication. Certainly, if a mucosal injury has occurred, a Dor fundoplication may decrease the risk of a leak and prevent reflux in most patients. Otherwise it is important to make it sure that a fundoplication will not cause any added resistance at the level of the GEJ. In cases when the esophagus is dilated, or when part of the fundus of the stomach has been damaged during the dissection, is better to avoid performing a fundoplication. If the patient develops abnormal reflux, it can be treated with proton pump inhibitors. Loviscek et al. recently showed excellent results using this approach [27]. They analyzed the outcome in 43 achalasia patients who had re-do Heller myotomy for recurrent dysphagia between 1994 and 2011. The only take down of the previous fundoplication was performed in 3 patients, while a redo myotomy extending for 3 cm onto the gastric wall was also performed in the remaining 40 patients. A fundoplication was recreated in only about one quarter of these patients. All patients were followed for at least 1 year after the operation. At a median follow-up of 63 months in 24 patients, improvement of dysphagia, with median overall satisfaction rating of 7 (range 3–10) was reported in 19 patients (79 %). An esophagectomy was necessary in four patients for persistent dysphagia. Other authors have reported similar results [30–32].

Sometimes patients present with recurrent dysphagia after a Heller myotomy performed through either a left thoracotomy or a left thoracoscopic approach. Because there are no adhesions in the abdomen and the right side of the esophagus is free of scar tissue created by the first operation, a LHM can be safely performed on the right side of the esophagus with excellent outcomes [33]. Depending on the esophageal size, a partial fundoplication can be added to the myotomy.

Esophagectomy should be avoided whenever possible as it is associated with a mortality rate ranging between 2 and 4 % and high morbidity even in expert hands and high volume Centers [34, 35]. For instance, Devaney et al. reported a 10 % rate of anastomotic leak, 5 % rate of hoarseness, and 2 % rate of bleeding and chylothorax requiring thoracotomy among 93 patients who had an esophagectomy for achalasia [35]. In addition, dysphagia secondary to an anastomotic stricture requiring dilatation occurred in 46 % of patients, regurgitation was complaint by 42 % of patients, and dumping syndrome was demonstrated in 39 % of patients. The average hospital stay was 12.5 days. Despite these shortcomings, esophagectomy is sometimes the only option in patients with end-stage achalasia, dilated and sigmoid shaped esophagus who have already had a failed Heller myotomy and sometimes a re-do Heller myotomy. When performing an esophagectomy, we prefer to use the stomach as an esophageal substitute. Because the esophagus is frequently dilated and fed by large blood vessels, the dissection of the thoracic esophagus is safer under direct vision, either thoracoscopically or by a right thoracotomy. The esophago-gastric anastomosis can be placed either in the neck or at the apex of the right chest.

A peroral endoscopic myotomy (POEM) is a new treatment modality proposed in achalasia patients, with short term relief of dysphagia in most patients [36, 37]. Because LHM is performed on the anterior wall of the esophagus, POEM could be used instead of a redo Heller myotomy in patients with persistent or recurrent dysphagia by performing a myotomy on the posterior wall of the esophagus [38, 39]. For instance, Onimaru et al. reported excellent short-term results in ten patients undergoing POEM for recurrent dysphagia after Heller myotomy [38]. At 3 months after POEM, the lower esophageal sphincter pressure decreased from 22.1 ± 6.6 to 10.9 ± 4.5 mmHg and the Eckardt score decreased from 6.5 ± 1.3 to 1.1 ± 1.3. Long term follow-up will be needed to confirm the validity of these short term results.

A LHM with partial fundoplication is today the recommended treatment modality for achalasia patients. The technical steps have been clearly established, and failure to follow them is the main cause of persistent or recurrent dysphagia.

Even though the success rate of LHM is very high, recurrence of symptoms eventually occurs in some patients, with the need for further treatment, particularly if the first operation was done at an early age. When this occurs, a thorough work-up is important for the identification of the cause and to plan a tailored treatment. The best outcomes are obtained in high volume Centers where radiologists, gastroenterologists and surgeons with experience in the diagnosis and treatment of this disease work as a team.