World Journal of Surgery

, Volume 42, Issue 5, pp 1469–1476 | Cite as

Esophagectomy for End-Stage Achalasia: Systematic Review and Meta-analysis

  • Alberto Aiolfi
  • Emanuele Asti
  • Gianluca Bonitta
  • Luigi Bonavina
Scientific Review



Indications for surgery and clinical outcomes of esophagectomy in the management of end-stage achalasia are not clearly defined. The aim of this systematic review and meta-analysis was to provide evidence-based information to help in the decision-making and in the choice of surgical technique.


An extensive literature search was conducted to identify all reports on esophagectomy for end-stage achalasia patients over the past three decades. MEDLINE, Embase and Cochrane databases were thoroughly consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy” and “esophageal resection” with “AND” and “OR.” Short- and long-term outcome data were extracted. Pooled prevalence of pneumonia, anastomotic leakage and mortality were calculated using Freeman–Tukey double arcsine transformation and DerSimonian–Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I 2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.


Eight papers published between 1989 and 2014 matched the inclusion criteria. In total, 1307 patients were included. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach. The stomach was used as an esophageal substitute in 95% of patients. Pooled prevalence of pneumonia, anastomotic leakage and mortality were 10% (95% CI 4–18%), 7% (95% CI 4–10%) and 2% (95% CI 1–3%), respectively.


Esophagectomy for end-stage achalasia is safe and effective. Based on the results of this study, esophagectomy should be performed without hesitation in patients who are fit for major surgery and present with disabling symptoms, poor quality of life and dolichomegaesophagus recalcitrant to multiple endoscopic dilatations and/or surgical myotomies.


  1. 1.
    Mayberry JF (2001) Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am 11:235–248PubMedGoogle Scholar
  2. 2.
    Tustumi F, Bernardo WM, da Rocha JRM et al (2017) Esophageal achalasia: a risk factor for carcinoma. A systematic review and meta-analysis. Dis Esophagus 30:1–8CrossRefPubMedGoogle Scholar
  3. 3.
    Boeckxstaens GE, Zaninotto G, Richter JE (2014) Achalasia. Lancet 383(9911):83–93CrossRefPubMedGoogle Scholar
  4. 4.
    Campos GM, Vittinghoff E, Rabl C et al (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249(1):45–57CrossRefPubMedGoogle Scholar
  5. 5.
    Asti E, Sironi A, Lovece A et al (2017) Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia. Surgery 161:977–983CrossRefPubMedGoogle Scholar
  6. 6.
    Moonen A, Annese V, Belmans A et al (2016) Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 65(5):732–739CrossRefPubMedGoogle Scholar
  7. 7.
    Vela MF, Richter JE, Wachsberger D et al (2004) Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol 99(6):1029–1036CrossRefPubMedGoogle Scholar
  8. 8.
    Watson TJ (2015) Esophagectomy for end-stage achalasia. World J Surg 39(7):1634–1641. doi: 10.1007/s11605-007-0226-8 CrossRefPubMedGoogle Scholar
  9. 9.
    Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25(9):603–605CrossRefPubMedGoogle Scholar
  11. 11.
    Freeman MF, Tukey JW (1950) Transformations related to the angular and the square root. Ann Math Stat 21(4):607–611CrossRefGoogle Scholar
  12. 12.
    Miller JJ (1978) The inverse of the Freeman–Tukey double arcsine transformation. Am Stat 32:138Google Scholar
  13. 13.
    DerSimonian R, Laird N (1986) Meta-analysis in clinical trials. Control Clin Trials 7(3):177–188CrossRefPubMedGoogle Scholar
  14. 14.
    Clopper CJ, Pearson ES (1934) The use of confidence or fiducial limits illustrated in the case of the binomial. Biometrika 26(4):404–413CrossRefGoogle Scholar
  15. 15.
    Borenstein M, Hedges LV, Higgins JPT et al (2009) Introduction to meta-analysis. Wiley, ChichesterCrossRefGoogle Scholar
  16. 16.
    Anzures-Cabrera J, Higgins JP (2010) Graphical displays for meta-analysis: an overview with suggestions for practice. Res Synth Methods 1(1):66–80CrossRefPubMedGoogle Scholar
  17. 17.
    Egger M, Davey Smith G, Schneider M et al (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315(7109):629–634CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    R Development Core Team (2015) A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna. ISBN 3-900051-07-0Google Scholar
  19. 19.
    Orringer MB, Stirling MC (1989) Esophageal resection for achalasia: indications and results. Ann Thorac Surg 47(3):340–345CrossRefPubMedGoogle Scholar
  20. 20.
    Pinotti HW, Cecconello I, da Rocha JM et al (1991) Resection for achalasia of the esophagus. Hepatogastroenterology 38(6):470–473PubMedGoogle Scholar
  21. 21.
    Peters JH, Kauer WK, Crookes PF et al (1995) Esophageal resection with colon interposition for end-stage achalasia. Arch Surg 130(6):632–636CrossRefPubMedGoogle Scholar
  22. 22.
    Miller DL, Allen MS, Trastek VF et al (1995) Esophageal resection for recurrent achalasia. Ann Thorac Surg 60(4):922–925CrossRefPubMedGoogle Scholar
  23. 23.
    Banbury MK, Rice TW, Goldblum JR et al (1999) Esophagectomy with gastric reconstruction for achalasia. J Thorac Cardiovasc Surg 117(6):1077–1084CrossRefPubMedGoogle Scholar
  24. 24.
    Devaney EJ, Iannettoni MD, Orringer MB et al (2001) Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg 72(3):854–858CrossRefPubMedGoogle Scholar
  25. 25.
    Tank AK, Kumar A, Babu TL et al (2009) Resectional surgery in achalasia cardia. Int J Surg 7(2):155–158CrossRefPubMedGoogle Scholar
  26. 26.
    Molena D, Mungo B, Stem M et al (2014) Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg 18(2):310–317CrossRefPubMedGoogle Scholar
  27. 27.
    Schuchert MJ, Luketich JD, Landreneau RJ et al (2009) Minimally invasive surgical treatment of sigmoidal esophagus in achalasia. J Gastrointest Surg 13(6):1029–1035CrossRefPubMedGoogle Scholar
  28. 28.
    Palanivelu C, Rangarajan M, Jategaonkar PA et al (2008) Laparoscopic transhiatal esophagectomy for ‘sigmoid’ megaesophagus following failed cardiomyotomy: experience of 11 patients. Dig Dis Sci 53(6):1513–1518CrossRefPubMedGoogle Scholar
  29. 29.
    Yibulayin W, Abulizi S, Lv H et al (2016) Minimally invasive oesophagectomy versus open esophagectomy for resectable esophageal cancer: a meta-analysis. World J Surg Oncol 14(1):304CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Biere SS, van Berge Henegouwen MI, Bonavina L et al (2017) Predictive factors for post-operative respiratory infections after esophageal cancer: outcome of randomized trial. J Thorac Dis 9(Suppl8):S861–S867CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Duranceau A, Liberman M, Martin J et al (2012) End-stage achalasia. Dis Esophagus 25(4):319–330CrossRefPubMedGoogle Scholar
  32. 32.
    Felix VN (2016) Esophagectomy for end-stage achalasia. Ann N Y Acad Sci 1381(1):92–97CrossRefPubMedGoogle Scholar
  33. 33.
    Bonavina L, Chella B, Segalin A (1998) Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 65(5):1446–1448CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2017

Authors and Affiliations

  1. 1.Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San DonatoUniversity of MilanSan Donato MilaneseItaly

Personalised recommendations