Myotomy in sigmoid megaesophagus: is it applicable? A systematic review and meta-analysis

Abstract

Summary Introduction: Achalasia may evolve to sigmoid megaesophagus in 10–15% of patients and is usually treated with esophagectomy, which has high morbi-mortality. Many surgeons debate the applicability of the Heller myotomy for treating sigmoid megaesophagus. This study intents to analyze the effectiveness of myotomy for treating patients with sigmoid megaesophagus. Methods: A systematic review and meta-analysis was conducted in PubMed, Cochrane, Lilacs and Embase alongside manual search of references. The inclusion criteria were clinical trials, cohort, case-series; patients with sigmoid megaesophagus and esophageal diameter ≥ 6 cm; and patients undergoing primary myotomy. The exclusion criteria were reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; previous surgical treatment for achalasia; and pediatric or animal model studies. No restrictions on language and date of publication, and no filters were applied. Subgroups analyses were performed to assess the laparoscopic myotomy perioperative outcomes. Besides, subgroup analyses were performed to assess the long-term outcomes of the studies with a follow-up time > 24 months. To verify heterogeneity, the I2 test was used. The random effects were applied, and the fixed model was evaluated as sensitivity analysis. To assess risk of bias and certainty of evidence, the tools ROBINS-I and GRADE were used, respectively. Registration number: CRD42020199667. Results: Sixteen articles were selected, encompassing 350 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. Complications rate was 0.08 (CI: 0.040–0.153; P = 0.01). Need for retreatment rate was 0.128 (CI: 0.031–0.409; P = 0.01). The probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.703–0.812; P < 0.01). Postoperative mortality rate was 0.008 (CI: 0.004–0.015; P < 0.01). Conclusion: Surgical myotomy is an option for avoiding esophagectomy in achalasia, with a low morbi-mortality rate and good results. It is effective for most patients and only a minority will demand retreatment.

Evaluating the Non-conventional Achalasia Treatment Modalities

“…Besides, these procedures should be performed only in high-volume institutions by high experienced upper gastrointestinal surgeons (Level 2b; Grade: B) (26,27). Even for sigmoid-shaped achalasia, the Hellermyotomy with a pull-through technique should be preferred over esophagectomy whenever it is possible (Level 2a; Grade: B) (8).…”

“…A sigmoid-shaped megaesophagus should not be indicated for any endoscopic therapy since the esophageal axis can not be properly corrected with endoscopy (4,8). The 2018 ISDE guideline recommends against temporary (absorbable or retrievable) stents and intersphincteric injection with sclerotherapy for achalasia due to the low volume of scientific papers (4).…”

“…The pneumatic dilatations were considered effective, but patients desiring long-term symptoms remission may be more appropriately referred to surgery or POEM. Sigmoid shaped megaesophagus should not be indicated for endoscopic therapy (4,8).…”

Management of Symptoms Recurrence After Myotomy for Achalasia. A Practical Approach

“…The reasons for recurrence are vast, and the risk of treatment failure depends on the preoperative achalasia grade. An advanced megaesophagus has a 12.8% retreatment risk after Heller myotomy 16 . The monitoring of patients with symptoms persisting or recurring after a surgical myotomy may be challenging.…”