45 Surgical Management of Recurrent Achalasia Following POEM: Laparoscopic Redo Cardiomyotomy with Dor Fundoplication

Abstract Aim To demonstrate the technical feasibility and clinical rationale for a laparoscopic cardiomyotomy (LCM) and Dor fundoplication in a patient with recurrent achalasia following previous Peroral Endoscopic Myotomy (POEM), and to highlight considerations unique to managing this complex clinical scenario. Method The video demonstrates careful dissection of the dense fibrous reaction in the posterior mediastinum along the prior POEM plane. Careful dissection, release and extension of the myotomy distally, followed by anterior Dor fundoplication. This included a hitch stitch at the angle of His to stabilise the fundoplication, preventing slippage and improving the effectiveness of the surgery. Results The video demonstrates that the myotomy was successfully extended onto the gastric cardia without mucosal injury, confirmed with intraoperative OGD and leak test. Dense submucosal fibrosis was encountered, necessitating meticulous dissection to avoid mucosal breach. The procedure was completed successfully and the patient resumed oral intake of clear fluids, reporting an immediate improvement in symptoms. A water-soluble contrast swallow confirmed no leak and the patient was discharged on postoperative day one. Conclusions LCM with fundoplication after failed POEM is rare, with few cases reported in current literature. This video highlights the unique intraoperative challenges posed by fibrotic changes post-POEM and the utility of fundoplication to prevent reflux. This case adds to a limited but growing evidence that LCM is a safe and effective surgical technique in patients with recurrent achalasia post-POEM.