A team from Ann Arbor, Michigan, USA, investigated patient selection for esophagectomy for achalasia, as well as clinical experience.
In 1989, the researchers predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms, after prior esophagomyotomy or balloon dilatation for achalasia.
Patient selection in this group is challenging. The potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus.
The hospital records of 93 patients (mean age, 51 years) undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively. The results of operation were assessed using the authors' prospectively established Esophageal Resection Database.
Follow-up information was obtained through personal contact with the patients.
Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%).
|95% of patients ate well after esophagectomy for achalasia.|
|Annals of Thoracic Medicine|
A total of 94% of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% of cases.
Intraoperative blood loss was found to average 672 ml.
Postoperative length of stay averaged 12.5 days.
Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%).
There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis.
Follow-up averaged 38 months. In all, 95% of patients ate well; nearly 50% required an anastomotic dilatation; troublesome regurgitation was rare; and 4% had refractory postvagotomy dumping.
Dr Eric J. Devaney, of the University of Michigan Medical Center, Ann Arbor, concluded on behalf of his colleagues, "Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia."
"Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, and large aortic esophageal arteries. In addition, adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy must be thought about," he added.