Residual spasm above the myotomy effect. Laparoscopic heller myotomy and paraoral endoscopic myotomy, or POEM, are considered to be durable options for the management of achalasia. Evaluation of residual disease after intervention has often focused on parameters involving LES dysfunction, such as delay of clearance noted on time barium swallow, elevated integrated relaxation pressure, or IRP, by high-resolution manometry, or low distensibility index, or DI, by functional luminal imaging probe topography, or FLIP topography. Residual spasm above the myotomy effect may be present in cases where there was preserved contractile activity and a myotomy did not address the entire active component. Residual spasm above the myotomy effect is a possible outcome, but is an under-recognized problem. We present three cases illustrating detection and management of residual disease, not at the LES, but in the esophageal body above the myotomy effect in patients who underwent a heller myotomy for the definitive treatment of their achalasia. Detection of spasm above the myotomy effect may be performed by high-resolution manometry, endoscopy, and FLIP topography. We have found FLIP with 16-centimeter balloon to be most revealing of spasm above the myotomy effect. Management strategies of these residual spastic areas may include trials of supplements or medications. A trial of Botox guided by HRM or FLIP topography targeting the spastic area may be done, and in cases where a definitive intervention is needed, a completion myotomy via a POEM approach may be considered. This first case is a 43-year-old female who presented with dysphagia and was diagnosed with type 3 achalasia. Her preoperative manometry study demonstrated an elevated IRP and premature contractions. She underwent a laparoscopic heller myotomy four years ago. After the myotomy, she only had partial improvement of her dysphagia. Over the past few years, she had worsening dysphagia to solids, liquids, and pills. She has choking, regurgitation, decreased PO intake, chest tightness, and mild weight loss. An esophagram was unrevealing. An endoscopy demonstrated a non-dilated, non-fluid-filled esophagus. The effect of the myotomy was seen in the distal esophagus. Conditions were seen above the myotomy effect, and the gastroesophageal junction was patent with no resistance upon passage of the scope. No fundoplication was noted endoscopically. High-resolution manometry revealed a normal IRP, and residual contractile activity was noted in the mid-esophageal body. Flipped topography demonstrated a normal EGGA diameter and distensibility. Their worst sustained occluding contractions noted above the myotomy effect, approximately 7 to 12 centimeters above the coral diaphragm. The patient had no improvement with nitrates or a standard balloon dilation. The patient was offered a completion myotomy targeting the mid-esophageal body with the residual spasm above the myotomy effect. This composite image of the flipped topography demonstrates the area of spasm that was targeted for myotomy. Myotomy was performed with standard POEM technique, including injection to create a cushion in the submucosal space, incision to gain access into the submucosal space, and submucosal dissection with injection, dissection, and cautery when needed. Spastic activity was noted in the tunnel, as seen here, with the muscles obliterating the lumen of the tunnel. The tunnel was created to the myotomy effect. Selected myotomy was performed of the circular muscle fibers throughout the residual spastic component. After the myotomy, a repeat flip topography was performed and demonstrated resolution of the spasm. Disclosure was conducted with clip placement, and the patient was admitted for observation with a barium swallow the next day, demonstrating no evidence of leak, and was discharged home without any evidence of complication with resolution of her chest pain and dysphagia. In this next case, we see a 32-year-old male who had dysphagia and weight loss, and was diagnosed with achillesion underwent to Heller myotomy six years ago. While the dysphagia symptoms improved, the patient had moderate constant chest pain after myotomy. A high-resolution manometry demonstrated absent contractility. Endoscopy was done and revealed fluid in the esophagus and a dilated distal esophageal segment with a patent gastroesophageal junction and intact door fundoplication. And again, we saw some contractile activity above the myotomy effect. Flip topography demonstrated the myotomy effect, and these residual contractile bands noted proximal to the myotomy. The GE junction was noted to be patent with a normal diameter and distensibility. The patient was offered a botulinum toxin injection to determine if paralyzing the muscles of the residual activity alleviated his symptoms. The patient had complete resolution of chest pain after Botox injection, and after recurrence of the symptoms, elected to undergo a completion myotomy via the POEM approach. He had no complications and had resolution of his chest pain symptoms after the myotomy. This last patient is a 28-year-old who underwent a Heller myotomy for the treatment of type II achalasia. After the myotomy, he continued to have chest pain after the procedure. He had a patent gastroesophageal junction, but again, flip topography demonstrated residual spasm above the myotomy effect. After Botox injection demonstrated complete resolution of the chest pain symptoms for over a year, the patient elected to have completion myotomy when symptoms returned. He underwent a peroral endoscopic myotomy of the residual spastic component without any evidence of complication and did well after the procedure with resolution of the chest pain. In conclusion, residual spasm above the myotomy effect may be present in cases where there is preserved contractile activity and a myotomy did not address the entire active component. We found flip topography with a 16-centimeter balloon useful in detecting residual spasm above the myotomy effect. Botulinum toxin may be considered as a trial to determine symptom correlation. Completion myotomy via POEM may be considered for definitive treatment.

residual spasm

myotomy effect

achalasia

high-resolution manometry

FLIP topography