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Ann Thorac Surg 1995;60:922-925
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Esophageal Resection for Recurrent Achalasia

Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. This study examined esophageal resection as treatment for recurrence or treatment complications of achalasia.

Methods. From 1976 through 1992, 37 patients (20 men and 17 women) underwent esophageal resection after initial surgical treatment for achalasia. The median age was 56 years (range, 19 to 84 years). Initial surgical treatment consisted of modified Heller myotomy in 28 patients, combined myotomy and antireflux procedure in 6, and antireflux procedure alone in 3. Twenty-six patients required an additional surgical procedure before esophageal resection (70.3%). Indication for esophageal resection was obstructive symptoms in 30 patients, cancer in 3, bleeding in 2, and perforation during dilation in 2. Reconstruction was established with the stomach in 26 patients, colon in 6, and small bowel in 5. Anastomosis was at the cervical level in 20 patients (54.1%) and intrathoracic in 17 (45.9%).

Results. There were two operative deaths (5.4%), both caused by intraoperative hemorrhage during transhiatal resection. Twelve patients (32.4%) had complications, which included cardiac dysrhythmia in 3, cervical anastomotic leak in 2, transient vocal cord paralysis in 2, pneumonia in 2, pulmonary embolus in 2, and reexploration for bleeding in 1. Follow-up was complete in all patients and ranged from 1.4 to 16 years (median, 6.3 years). Excellent or good long-term functional results were present in 32 patients (91.4%).

Conclusions. Esophageal resection provides reasonable long-term functional results in patients with recurrence or treatment complications of achalasia. In our experience, transhiatal resection is associated with increased morbidity and mortality.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
See also page 925.

No cure currently exists for achalasia, and all therapies to alleviate symptoms are palliative. Esophagomyotomy can provide long-term relief of dysphagia. Unfortunately, recurrent symptoms or complications requiring surgical intervention develop in 10% to 15% of treated patients [1, 2]. The appropriate management of these patients, however, is controversial. Options usually include repeat esophagomyotomy or esophageal resection. We recently reviewed our experience in patients who underwent esophageal resection as a reoperative procedure for recurrent symptoms or treatment complications of achalasia.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From 1976 through 1992, 1,149 patients with achalasia were treated at the Mayo Clinic. Four hundred fifty-two patients (39.3%) underwent surgical treatment; however, only 37 (8.2%) had esophageal resection. No patient had esophageal resection as the initial surgical intervention. The medical record of each patient was examined for age, sex, duration and type of symptoms, previous surgical procedures, indications for esophageal resection, operative complications, and long-term follow-up. Functional results were recorded at 1, 3, 6, 9, 12, and 15 years. Four possible functional results were observed: excellent (asymptomatic), good (absence of symptoms except under unusual circumstances), fair (persistence of preresection symptoms but less severe), and poor (persistence or worse preresection symptoms or the development of new disabling symptoms). Operative mortality included patients who died within the first 30 days after operation or those who died during the same hospitalization. Survival was estimated by the Kaplan-Meier method, using the date of esophageal resection as the starting point and the date of death or last follow-up as the end point [3]. The influence of variables on function outcome was analyzed using the log-rank test and the Cox proportional hazards model for continuous variables [4–6].

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
There were 20 men and 17 women with a median age of 56 years (range, 19 to 84 years). Initial surgical treatment consisted of modified Heller myotomy in 28 patients, combined myotomy and antireflux procedure in 6, and Nissen fundoplication alone in 3. Subsequently, 26 patients (70.3%) underwent 33 additional surgical procedures before esophageal resection, which included a modified Heller myotomy in 15, combined myotomy and antireflux procedures in 6, antireflux procedure in 6, vagotomy and antrectomy in 2, and other in 4 (Table 1). The median interval between the first surgical procedure and esophageal resection was 13.2 years (range, 0.4 to 45.3 years).

The operative procedures to resect and reconstruct the esophagus varied. An Ivor Lewis esophagogastrectomy was performed in 12 patients (32.4%), a transhiatal esophagogastrectomy (THE) in 9 (24.3%), a colon interposition in 6 (16.3%) (in 2 of the 6 patients with colon interposition, the esophagus was removed at a later operation), an extended transthoracic esophagogastrectomy (right thoracotomy, laparotomy, and cervical anastomosis) in 5 (13.5%), and a distal esophageal resection, gastric antrectomy, and Roux-en-Y procedure in 5 (13.5%).

There were two operative deaths (5.4%). Both deaths occurred intraoperatively due to uncontrolled hemorrhage during THE. Each patient had undergone two previous esophagomyotomies and multiple pneumatic dilations.

Complications occurred in 12 patients (32.4%). Two patients experienced cervical anastomotic leaks, 1 after THE and 1 after extended transthoracic esophagogastrectomy. Both were treated nonoperatively and each healed spontaneously. Cardiac dysrhythmias developed in 3 patients, pneumonia in 2, transient vocal cord paralysis in 2, and pulmonary emboli in 2. One patient required reoperation within the first 24 hours to control bleeding from a paraesophageal vessel after a THE. Median hospitalization was 12 days (range, 8 to 58 days).

Follow-up was complete in all 35 operative survivors and ranged from 1.4 to 16 years (median, 6.3 years). Excellent results were present in 26 patients (74.3%) and good results in 6 (17.1%). The 3 remaining patients had fair results, 1 each after THE, colon interposition, and Roux-en-Y procedure. Five patients (14.3%) required esophageal dilation for dysphagia from anastomotic narrowing during the first year after resection. There were 24 patients available for follow-up 6 years after their resection. Dysphagia was present in 5 (20.8%) and regurgitation in 2 (8.3%); no patient complained of dumping or weight loss. The 3 patients with esophageal cancer all died of metastatic disease within 12 months after resection.

To determine if the type of resection and reconstruction significantly affected morbidity, mortality, or long-term functional outcome, we divided the 37 patients into five groups: THE (9 patients), transthoracic esophagogastrectomy (12 patients), extended transthoracic esophagogastrectomy (5 patients), distal esophageal resection, antrectomy, and Roux-en-Y (5 patients), and colonic interposition (6 patients). No difference was observed between the groups with regard to age, sex, presenting symptoms, or previous surgical procedures. A significant increase in the amount of blood loss and number of transfusions was observed in the THE group (p < 0.05) (Table 2). Also, a significant increase in the number of intraoperative complications (44.4%) occurred in the THE group (p < 0.05) (see Table 2).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Ellis and associates [12] reported that only two thirds of patients undergoing repeat esophagomyotomy were improved and that the addition of a fundoplication did not further improve the patient. However, when esophageal resection was performed, they reported symptomatic improvement in all patients. These authors concluded that esophageal resection should be used in all patients who require reoperation. When to proceed with esophageal resection rather than to attempt another esophagomyotomy, in our experience, must be individualized. If evaluation demonstrates minimal evidence of an esophagomyotomy and the esophagus is not markedly dilated, then repeat esophagomyotomy should be considered. If a hiatal hernia is present with symptoms of either obstruction or gastroesophageal reflux, a partial fundoplication should be performed concomitantly with the esophagomyotomy [17]. However, if the esophagus is markedly dilated and an adequate esophagomyotomy has been performed, as judged by barium swallow and manometry, resection is a better treatment option. Finally, for those patients with two or more previously failed operations, resection is our treatment of choice.

Our experience demonstrated that the method of esophageal resection and reconstruction affected outcome. Patients who had THE experienced more intrathoracic bleeding than those who had transthoracic esophageal resection. Adhesions from previous operations makes mediastinal dissection difficult and no doubt contributes to the 33% hemorrhage rate (3/9) observed in the present report. In contrast, we previously reported a hemorrhage rate of only 0.9% with THE for esophageal cancer [18]. This report encompassed 131 patients who underwent THE during approximately the same period as the current report, so the high rate of hemorrhage cannot be explained solely by lack of experience with THE. The dense adhesions make THE more difficult, and it should be used with reservation in patients who have had multiple prior operations for achalasia. For this reason, we believe that transthoracic esophageal resection is the preferred method of resection. Transthoracic esophagogastrectomy with high intrathoracic or cervical anastomosis can be accomplished safely with low operative morbidity and mortality. This approach yields excellent long-term functional results, because most of the nonfunctional esophagus is resected.

Others have advocated THE as the best procedure to resect the esophagus when achalasia has rendered it nonfunctional [19, 20]. However, Orringer and Stirling [19] reported that in 8% (2/26) of patients treated with THE the procedure had to be converted to a thoracotomy to resect the esophagus. Two other of their patients required reexploration for hemorrhage (1 subsequently died) and 2 required thoracotomy for postoperative chylothorax. Moreover, these complications occurred even though 15% of their patients had THE as their only operation for achalasia. Pinotti and associates [28] describe similar problems with THE for achalasia, including a 2% mortality due to hemorrhage. Recognizing these complications, Pinotti and associates described division of the diaphragm to allow better exposure of the mediastinum during THE, which is necessary if the dilated, scarred esophagus is to be safely resected. In our group of patients, all of whom had undergone previous operations and more than 70% of whom had undergone multiple procedures, transhiatal resection, as would be expected, led to an unacceptably high hemorrhage rate.

Although the method of resection affected outcome, the choice of conduit to replace the esophagus did not affect long-term function. In more than two thirds of our patients, stomach was used to reconstruct the esophagus, preferably because of its ease of use, reliable blood supply, and a single anastomosis. When the stomach was unavailable, colon or small bowel was used for reconstruction. Although technically more difficult, both latter conduits yielded acceptable long-term function.

We conclude that in patients with achalasia in whom recurrent symptoms develop or who have complications after initial surgical management, esophageal resection provides reasonable long-term functional results. In our experience, transhiatal esophageal resection is associated with increased morbidity and mortality.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10-12, 1994.

Address reprint requests to Dr Allen, Section of General Thoracic Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Daniel L. Miller Mark S. Allen Victor F. Trastek Claude Deschamps Peter C. Pairolero Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Miller, D. L. Articles by Pairolero, P. C. Search for Related Content PubMed PubMed Citation Articles by Miller, D. L. Articles by Pairolero, P. C. Related Collections Related Article