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Esophagectomy for stage IV achalasia

Case series and literature review

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Summary

Background

Achalasia is a rare esophageal motility disorder characterized by defective lower esophageal sphincter relaxation and esophageal body aperistalsis. Endoscopic balloon dilation and laparoscopic myotomy are effective initial treatments in patients with early-stage disease. Indications for upfront esophagectomy in stage IV disease are still debated.

Methods

Retrospective, observational, single center study including consecutive patients who underwent esophagectomy for end-stage achalasia. A literature search was performed additionally.

Results

Out of 385 patients referred to our department for achalasia, 6 (1.6%) had previous unsuccessful surgical myotomy and underwent esophagectomy for stage IV disease. There were 4 females and the median age was 54.4 years (range 33–69). Most commonly reported symptoms were regurgitation (100%), dysphagia (83%), chest pain (67%), and recurrent episodes of pneumonia and/or chronic cough (50%). Two patients were incidentally diagnosed with squamous-cell carcinoma in the surgical specimen. A hybrid Ivor-Lewis esophagectomy was the most commonly performed operation. The median operative time was 320 min (range 290–365). The median in-hospital stay was 13 days. No anastomotic leaks occurred. The overall postoperative morbidity rate was 33% and there was no mortality. A total of 1422 esophagectomies for end-stage achalasia were reported in the literature. The stomach was the most commonly used esophageal substitute (94%). The anastomotic leak rate varied from 0 to 17%, and the postoperative mortality from 0 to 5.4%.

Conclusion

Selected stage IV achalasia patients with recurrent and disabling symptoms after previously failed Heller myotomy and/or endoscopic treatments should be offered minimally invasive esophagectomy.

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Authors and Affiliations

  1. Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Edmondo Malan, 1, 20097, Milan, Italy

    Alberto Aiolfi MD, Emanuele Asti MD, Carlo Galdino Riva MS &  Luigi Bonavina MD

Authors
  1. Alberto Aiolfi MD
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  2. Emanuele Asti MD
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  3. Carlo Galdino Riva MS
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  4. Luigi Bonavina MD
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Corresponding author

Correspondence to Luigi Bonavina MD.

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Conflict of interest

A. Aiolfi, E. Asti, C.G. Riva, and L. Bonavina declare that they have no competing interests.

Ethical standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study.

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Aiolfi, A., Asti, E., Riva, C.G. et al. Esophagectomy for stage IV achalasia. Eur Surg 50, 58–64 (2018). https://doi.org/10.1007/s10353-018-0514-4

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