Non-conventional surgical approach to achalasia: mucosectomy and endomuscular pull-through

Abstract

Aim: Transhiatal esophagectomy is a therapeuthic option for the treatment of end-stage achalasia that avoids the complications of a thoracotomy. This technique; however, is still linked to some degree of morbimortality especially due to pleuromediastinal complications. Esophageal mucosectomy and endomuscular pull-through could avoid these complications. This study aims to evaluate the short and long-term outcomes of esophageal mucosectomy and endomuscular pull-through in a series of patients with advanced megaesophagus. Methods: We retrospectively studied 115 patients with end-stage achalasia that underwent esophageal mucosectomy and endomuscular pull-through. Digestive tract reconstruction was accomplished most times using the stomachthourgh the muscular tunnel. Outcomes were evaluated in a short and long-term follow-up based on clinical, endoscopic and tomographic evaluation. Results: Anastomotic leak or stenosis was present in 27%. Pleural efusion was noticed in 11% and pneumonia in 9%. Mortality was 1.7%. Long-term follow-up (over 10 years) was possible in 42 patients. Excellent and good clinical results were obtained in 83% of the patients. Conclusion: Esophageal mucosectomy and endomuscular pull-through is a valuable procedure for the treatment of end-stage achalasia. It shows a low rate of complications and good outcomes at long-term follow-up. Key words:Achalasia, esophagectomy, megaesophagus, mucosectomy ABSTRACTArticle history:

Comparative Analysis of Late Results of Cervical Esophagogastric Anastomosis by Manual and Mechanical Suture in Patients Submitted to Esophageal Mucosectomy Through Advanced Megaesophagus

“…And this fact was already evident in other studies performed by us, but with a smaller number of patients and with the cervical esophagogastric anastomosis performed only with manual suture and with imaging tests by thorax tomography, evidencing that the permanence of the muscular layer in the posterior mediastinum does not seem to have compromised the gastric transposition for reconstruction of the digestive tract after esophageal mucosectomy 3 , 7 .…”

“…The regurgitation was around 25% in both groups and was resolved after proper diet. This change is described in up to 50% in patients who undergo gastric transposition to replace the esophagus either by benign or malignant conditions 3 , 4 , 5 , 6 , 8 , 18 , 19 , 20 , 23 , 30 . This is usually a consequence of gastric stasis and if a proper diet is followed, the patients usually adapt well without compromising the usual activities.…”

“…All patients underwent esophageal mucosectomy with preservation of the muscular layer, according to the technique standardized by Aquino et al 3 6 .…”

Surgical Treatment of Esophageal Advanced Achalasia

“…Consequently, the food transit towards the stomach becomes hampered, which makes the patient present dysphagia as the main symptom. Other symptoms such as regurgitation of saliva and undigested food, heartburn, chest pain and respiratory symptoms such as nocturnal cough, recurrent aspiration and pneumonia have also been reported [1,2].…”

“…Although idiopathic achalasia and Chagas disease have different etiologies, both conditions have, in fact, the same clinical, radiological, endoscopic and manometric presentation [1][2][3].…”