Management of recurrent end-stage achalasia with robotic-assisted esophagectomy: a case report and literature review.

Introduction and importance: Achalasia, an uncommon esophageal motility disorder, presents therapeutic challenges, especially in refractory cases with a history of multiple surgeries. Here, we present a complex case illustrating the dilemmas and multidisciplinary approach required in managing such patients. This case underscores the relevance of newer techniques like robotic-assisted esophagectomy in refractory achalasia management.

Case presentation: A 53-year-old male with recurrent achalasia endured persistent dysphagia, reflux, and esophageal spasms despite undergoing Heller myotomies, fundoplications, and hiatal hernia repairs. Imaging revealed severe esophageal dilation and anatomical alterations post-surgeries. Opting for a robotic-assisted thoracoabdominal esophagectomy due to relentless symptoms, the patient faced technical hurdles due to adhesions and a dilated esophagus. Post-surgery, complications like thoracic duct injury, milky pleural effusion, atrial fibrillation, and limb ischemia arose, necessitating multidisciplinary intervention.

Clinical discussion: Managing refractory achalasia poses significant challenges, particularly in extensively operated patients. Despite aggressive surgeries, debilitating symptoms persisted, emphasizing the need for a multidisciplinary approach. Complications like thoracic duct injury and atrial fibrillation further complicate management, highlighting the intricacies of such cases. Careful consideration of surgical options and the potential of newer techniques like POEM are crucial in navigating such complexities.

Conclusion: Managing refractory achalasia, especially in patients with extensive surgical histories, requires a multidisciplinary approach and careful consideration of treatment options. This case underscores the evolving landscape of achalasia management and emphasizes the potential benefits of newer techniques like POEM in select cases.