Esophagectomy for end‐stage achalasia

Abstract

End-stage achalasia is rarely effectively addressed with conservative treatments, as food must traverse a serpiginous route to reach the stomach. Botox injections in the setting of end-stage achalasia will likely provide minimal temporary palliation at best, pneumatic dilation has higher risks of perforation, and laparoscopic myotomy, while minimally invasive, has presented poor results. Under these circumstances, there are many proposed procedures to restore a viable alimentary condition to patients, from partial to subtotal resection of the esophagus; each of procedures confers both advantages and specific risks. Subtotal esophagectomy must be indicated for end-stage disease (tortuous or sigmoid esophagus) and persistent dysphagia after failed interventions. When performed by experienced hands, the procedure can be undertaken successfully, with acceptable postoperative morbidity and mortality, improvement of symptoms, and a good long-term quality of life in the majority of patients.

Management of achalasia cardia: Expert consensus statements

“…Problems with the transthoracic approach include morbidity of thoracotomy and risk of anastomotic leak in the chest. Lastly, the problems associated with minimally invasive approaches are need for a high level of skill and scarcity of adequately experienced surgeons . A retrospective study conducted by Devaney et al .…”

“…Lastly, the problems associated with minimally invasive approaches are need for a high level of skill and scarcity of adequately experienced surgeons. 113,114 A retrospective study conducted by Devaney et al looked at 20 years of patient data and during that time, 93 patients underwent esophagectomy for achalasia. 115 Indications for esophagectomy to treat AC include megaesophagus in 59 (64%) and 9 (10%) of those with no prior treatment, and prior esophageal procedure in 85 (90%) including dilatation in 66 (71%), myotomy in 58 (62%), anti-reflux operation in 29 (31%), and other in 16 (17%).…”

Achalasia: what to do in the face of failures of Heller myotomy

“…29 Progression to end-stage achalasia generally follows from the failure of repeated treatment interventions and is characterized by marked dilation, tortuosity, and sigmoidization of the esophagus. 33 The progression of the disease after HM to endstage achalasia is characterized by the persistence of dysphagia and regurgitation and leaves little alternative to esophagectomy. 28,29 Among the causes of dysphagia persistence or recurrence in those undergoing myotomy and fundoplication, incomplete myotomy, postoperative fibrosis, and disease progression frequently result in a dilated and tortuous esophagus.…”

“…In the absence of therapy or when therapy is ineffective, progressive dilatation and increasing tortuosity of the esophagus occur and result in worsening of outlet obstruction and retention of saliva and food. 33 Esophageal resection may be required in patients with end-stage achalasia to restore alimentary transit, reverse nutritional deficiencies, and reduce the risk of aspiration pneumonia and carcinoma. End-stage achalasia is typically characterized by a dilated (>6 cm) and sigmoid esophagus (dolichomegaesophagus) and is diagnosed in about 5% of patients.…”

One size fits all: laparoscopic Heller’s myotomy for the treatment of achalasia irrespective of the degree of dilatation

“…The number of esophagectomies for the treatment of achalasia has been decreasing after the 1990s [28] in favor of less invasive methods since esophagectomy is associated with significant complications and mortality [29] . Moreover, surgical risk is directly linked to the degree of esophageal dilatation [30] .…”