European Surgery

, Volume 50, Issue 2, pp 58–64 | Cite as

Esophagectomy for stage IV achalasia

Case series and literature review
  • Alberto Aiolfi
  • Emanuele Asti
  • Carlo Galdino Riva
  • Luigi Bonavina
original article
  • 37 Downloads

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.

Keywords

Achalasia End-stage achalasia Megaesophagus Sigmoid esophagus Esophageal resection Esophageal carcinoma 

Notes

Compliance with ethical guidelines

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.

References

  1. 1.
    Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet. 2014;383(9911):83–93.CrossRefPubMedGoogle Scholar
  2. 2.
    Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg. 2009;249(1):45–57.CrossRefPubMedGoogle Scholar
  3. 3.
    Moonen A, Annese V, Belmans A, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut. 2016;65(5):732–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Asti E, Sironi A, Lovece A, et al. Health-related quality of life after laparoscopic Heller myotomy and Dor fundoplication for achalasia. Surgery. 2017;161(4):977–83.CrossRefPubMedGoogle Scholar
  5. 5.
    Vela MF, Richter JE, Wachsberger D, et al. Complexities of managing achalasia at a tertiary referral center: use of pneumatic dilatation, Heller myotomy, and botulinum toxin injection. Am J Gastroenterol. 2004;99(6):1029–36.CrossRefPubMedGoogle Scholar
  6. 6.
    Duranceau A, Liberman M, Martin J, et al. End-stage achalasia. Dis Esophagus. 2012;25(4):319–30.CrossRefPubMedGoogle Scholar
  7. 7.
    Patti MG, Feo CV, Diener U, et al. Laparoscopic Heller myotomy relieves dysphagia when the esophagus is dilated. Surg Endosc. 1999;13:843–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Mineo TC, Pompeo E. Long-term outcome of Heller myotomy in achalasic sigmoid esophagus. J Thorac Cardiovasc Surg. 2004;128:402–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Devaney EJ, Iannettoni MD, Orringer MB, et al. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg. 2001;72(3):854–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Lehman MB, Clark SB, Ormsby AH, et al. Squamous mucosal alterations in esophagectomy specimens from patients with end-stage achalasia. Am J Surg Pathol. 2001;25(11):1413–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Zendehdel K, Nyrén O, Edberg A, et al. Risk of esophageal adenocarcinoma in achalasia patients, a retrospective cohort study in Sweden. Am J Gastroenterol. 2011;106:57–61.CrossRefPubMedGoogle Scholar
  12. 12.
    Tustumi F, Bernardo WM, da Rocha JRM, et al. Esophageal achalasia: a risk factor for carcinoma. A systematic review and meta-analysis. Dis Esophagus. 2017;30:1–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Bonavina L, Nosadini A, Bardini R, et al. Primary treatment of esophageal achalasia. Long-term results of myotomy and Dor fundoplication. Arch Surg. 1992;127:222–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992;103:1732–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Bonavina L, Bona D, Binyom PR, et al. A laparoscopy-assisted surgical approach to esophageal carcinoma. J Surg Res. 2004;117(1):52–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Bonavina L, Asti E, Sironi, et al. Hybrid and total minimally invasive esophagectomy: how I do it. J Thorac Dis. 2017;9(Suppl 8):S761–S72.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Watson TJ. Esophagectomy for end-stage achalasia. World J Surg. 2015;39(7):1634–41.CrossRefPubMedGoogle Scholar
  18. 18.
    Aiolfi A, Asti E, Bonitta G, et al. Esophagectomy for end-stage achalasia: systematic review and meta-analysis. World J Surg. 2017;  https://doi.org/10.1007/s00268-017-4298-7.Google Scholar
  19. 19.
    Orringer MB, Stirling MC. Esophageal resection for achalasia: indications and results. Ann Thorac Surg. 1989;47(3):340–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Pinotti HW, Cecconello I, da Rocha JM, et al. Resection for achalasia of the esophagus. Hepatogastroenterology. 1991;38(6):470–3.PubMedGoogle Scholar
  21. 21.
    Peters JH, Kauer WK, Crookes PF, et al. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg. 1995;130(6):632–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Miller DL, Allen MS, Trastek VF, et al. Esophageal resection for recurrent achalasia. Ann Thorac Surg. 1995;60(4):922–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Banbury MK, Rice TW, Goldblum JR, et al. Esophagectomy with gastric reconstruction for achalasia. J Thorac Cardiovasc Surg. 1999;117(6):1077–84.CrossRefPubMedGoogle Scholar
  24. 24.
    Hsu HS, Wang CY, Hsieh CC, et al. Short-segment colon interposition for end-stage achalasia. Ann Thorac Surg. 2003;76(5):1706–10.CrossRefPubMedGoogle Scholar
  25. 25.
    Gockel I, Kneist W, Eckardt VF, et al. Subtotal esophageal resection in motility disorders of the esophagus. Dig Dis. 2004;22(4):396–401.CrossRefPubMedGoogle Scholar
  26. 26.
    Glatz SM, Richardson JD. Esophagectomy for end stage achalasia. J Gastrointest Surg. 2007;11(9):1134–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Palanivelu C, Rangarajan M, Jategaonkar PA, et al. Laparoscopic transhiatal esophagectomy for ’sigmoid’ megaesophagus following failed cardiomyotomy: experience of 11 patients. Dig Dis Sci. 2008;53(6):1513–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Tank AK, Kumar A, Babu TL, et al. Resectional surgery in achalasia cardia. Int J Surg. 2009;7(2):155–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Lewandowski A. Diagnostic criteria and surgical procedure for megaesophagus—a personal experience. Dis Esophagus. 2009;22(4):305–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Schuchert MJ, Luketich JD, Landreneau RJ, et al. Minimally invasive surgical treatment of sigmoidal esophagus in achalasia. J Gastrointest Surg. 2009;13(6):1029–35.CrossRefPubMedGoogle Scholar
  31. 31.
    Crema E, Ribeiro LB, Sousa RC, et al. Laparoscopic transhiatal esophagectomy for the treatment of advanced megaesophagus. An analysis of 60 cases. Rev Col Bras Cir. 2009;36(2):118–22.CrossRefPubMedGoogle Scholar
  32. 32.
    Howard JM, Ryan L, Lim KT, et al. Oesophagectomy in the management of end-stage achalasia—case reports and a review of the literature. Int J Surg. 2011;9(3):204–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Carter YM, Bond CD, Benjamin S, et al. Minimally invasive transhiatal esophagectomy after thoracotomy. Ann Thorac Surg. 2013;95(2):e41–e3.CrossRefPubMedGoogle Scholar
  34. 34.
    Molena D, Mungo B, Stem M, et al. Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg. 2014;18(2):310–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Felix VN. Esophagectomy for end-stage achalasia. Ann N Y Acad Sci. 2016;1381(1):92–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

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

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