The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients.
We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25–83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure.
The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant.
MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients.
Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, Sharp KW. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective, randomized, double-blind clinical trail. Ann Surg 2004;240:405–415.PubMedCrossRefGoogle Scholar
Patti MG, Fisichella PM, Perretta S, Galvani C, Gorodner MV, Robinson T, Way LW. Impact of minimally-invasive surgery on the treatment of esophageal achalasia: a decade of change. J Am Coll Surg 2003;196:698–705.PubMedCrossRefGoogle Scholar
Patti MG, Feo CV, Diener U, Tamburini A, Arcerito M, Way LW. Laparoscopic Heller myotomy relieves dysphagia when the esophagus is dilated. Surg Endosc 1999;13:843–847.PubMedCrossRefGoogle Scholar
Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg 2004;128:402–407.PubMedCrossRefGoogle Scholar
Pinotti HW, Cecconello I, Mariano da Rocha J, Zilberstein B. Resection for achalasia of the esophagus. Hepatogastroenterology 1991;38:470–473.PubMedGoogle Scholar
Peters JH, Kauer WKH, Crookes PF, Ireland AP, Brenner CG, DeMeester TR. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg 1995;130:632–637.PubMedGoogle Scholar
Devaney EJ, Lannettoni MD, Orringer MB, Marshall B. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg 2001;72:854–858.PubMedCrossRefGoogle Scholar
Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Keenan RJ, Ikramuddin S, Schauer PR. Outcomes after minimally-invasive esophagomyotomy. Ann Thorac Surg 2001;72:1909–1913.PubMedCrossRefGoogle Scholar
Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, Schauer PR, Close JM, Fernando HC. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003;238(4):486–494.PubMedGoogle Scholar
Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW. Minimally-invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 1999;230(4):587–594.PubMedCrossRefGoogle Scholar
Rosemurgy A, Villadolid D, Thometz D, Kalipersad C, Rakita S, Albrink M, Johnson M, Boyce W. Laparoscopic Heller myotomy provides durable relief from achalasia and salvages failures after BoTox or dilation. Ann Surg 2005;241:725–735.PubMedCrossRefGoogle Scholar
Peracchia A, Segalin A, Bardini R, Ruol A, Bonavina L, Baessato M. Esophageal carcinoma and achalasia: prevalence, incidence and results of treatment. Hepatogastroenterology 1991;38:514–516.PubMedGoogle Scholar
Banbury MK, Rice TW, Goldblum JR, Clark SB, Baker ME, Richter JE, Rybicki LA, Blackstone EH. Esophagectomy with gastric reconstruction for achalasia. J Thorac Cardiovasc Surg 1999;117:1077–1085.PubMedCrossRefGoogle Scholar
Miller DL, Allen MS, Trastek VF, Deschamps C, Pairolero PC. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995;60:922–926.PubMedCrossRefGoogle Scholar
Schuchert MJ, Luketich JD, Fernando HC. Complications of minimally-invasive esophagectomy. Semin Thorac Cardiovasc Surg 2004;16(2):133–141.PubMedCrossRefGoogle Scholar
Torquati A, Richards WO, Holzman MD, Sharp KW. Laparoscopic myotomy for achalasia: predictors of successful outcome after 200 cases. Ann Surg 2006;243:587–593.PubMedCrossRefGoogle Scholar
Smith CD, Stival A, Howell DL, Swafford V. Endoscopic therapy for achalasia before Heller Myotomy results in worse outcomes than Heller myotomy alone. Ann Surg 2006;243(5):579–586.PubMedCrossRefGoogle Scholar
Portale G, Costantini M, Rizzetto C, Guirroli E, Ceolin M, Salvador R, Ancona E, Zaninotto G. Long-term outcome of laparoscopic Heller–Dor surgery for esophageal achalasia: possible detrimental role of previous endoscopic treatment. J Gastrointest Surg 2005;9(9):1332–1339.PubMedCrossRefGoogle Scholar
Schuchert MJ, Luketich JD, Landreneau RJ, Kilic A, Gooding WE, Alvelo-Rivera M, Christie NA, Gilbert S, Pennathur A. Minimally-invasive esophagomyotomy in 200 patients: factors influencing post-operative outcomes. Ann Thorac Surg 2008;85:1729–1734.PubMedCrossRefGoogle Scholar