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Ann Thorac Surg 2001;72:854-858
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Esophagectomy for achalasia: patient selection and clinical experience

^a Section of Thoracic Surgery, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA

Address reprint requests to Dr Orringer, Section of Thoracic Surgery, University of Michigan Medical Center, 1500 E Medical Center Dr, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109
e-mail: morrin{at}umich.edu

Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.

	Abstract

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Background. In 1989, we predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challenging, as the potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus.

Methods. The hospital records of 93 patients undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively and the results of operation assessed using our prospectively established Esophageal Resection Database and follow-up information obtained through personal contact with the patients.

Results. Patient age averaged 51 years. Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%). Ninety-four percent of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% cases. Intraoperative blood loss averaged 672 mL. Postoperative length of stay averaged 12.5 days. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis. Follow-up has averaged 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% have refractory postvagotomy dumping.

Conclusions. Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia. Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, large aortic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy.

	Introduction

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Achalasia is a degenerative neuromotor disease of the esophagus with characteristic clinical, radiographic, histologic, and manometric features. The etiology of achalasia in North America and Europe is unknown and its treatment is palliative. Therapy focuses on relieving the functional obstruction at the esophagogastric junction. Forceful dilatation of the esophagus and esophagomyotomy have gained wide acceptance as effective therapy for early achalasia. However, many patients present with end-stage achalasia, characterized by a tortuous megaesophagus, or with recurrent obstructive symptoms after prior esophageal dilatation or esophagomyotomy. In an increasing number of these patients, after careful selection, esophagectomy has been performed as an alternative to more conservative nonresective procedures. This report reviews our experience with 93 patients with achalasia treated predominantly with a transhiatal esophagectomy and a cervical esophagogastrostomy.

	Material and methods

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Since 1980, esophagectomy and esophageal reconstruction for achalasia have been performed by the Thoracic Surgery Service at the University of Michigan Medical Center in 93 patients. The clinical diagnosis was confirmed by the histopathology showing absence of the myenteric plexuses in the wall of the resected esophagus. The results have been analyzed retrospectively using our Esophageal Resection Database and follow-up through personal interviews and examinations, written correspondence, and telephone contacts with patients and families. This group consisted of 43 men (46%) and 50 women (54%), ranging in age from 14 to 89 years (mean 51 years). The indications for esophagectomy are shown in Table 1. A tortuous megaesophagus (diameter > 6 cm.) was present in 59 patients (64%); 9 of these had had no prior esophageal surgery or dilatations. An associated reflux stricture was present in 6 (7%). Of the patients, 66 (71%) had undergone prior dilatation (19 once, 9 twice, and 38 on three or more occasions). A total of 58 patients (62%) had undergone esophagomyotomy (49 once and 9 twice). In all, 29 patients (31%) had undergone an antireflux procedure either in isolation or in conjunction with an esophagomyotomy. Statistical analysis was performed using Spearman’s rank correlation, the Wilcoxon-Mann-Whitney test, and a ² test to assess factors influencing functional outcome.

	Results

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Follow-up is available for the 91 survivors; it ranges from 1 to 190 months (average 38 months). In assessing the functional results of esophageal substitution, the following factors have been analyzed: presence and degree of dysphagia, regurgitation, postvagotomy diarrhea and cramping (dumping), and weight status (Table 3). Postoperatively, early anastomotic dilatation on an outpatient basis is used for any degree of cervical dysphagia that is reported after discharge from the hospital. With this aggressive policy of dilatation, nearly 50% of patients have undergone at least one postoperative esophageal dilatation. At the time of their latest evaluation, 95% of patients are able to eat food of a normal consistency without postprandial regurgitation. Mild nocturnal regurgitation has occurred in 42%, but troublesome regurgitation has been rare, and no patient has had pulmonary complications secondary to aspiration of gastric contents. Mild dumping symptoms (postprandial cramping and diarrhea) have been reported by 39% of patients and have usually been self-limited or easily controlled with dietary modifications or medications (eg, diphenoxylate, loperamide, or tincture of opium). Severe refractory dumping has occurred in 4 patients, and 3 of these have required Somatostatin injections for its control. One half of the patients have lost weight (an average of 17 pounds) compared with their preoperative status, whereas the other half have either gained weight (also an average of 17 pounds) or remained stable. On the basis of their most recent follow-up evaluation, overall functional results were scored as excellent (ie, completely asymptomatic) in 26 patients (29%), good (mild symptoms requiring no treatment) in 38 (42%), fair (symptoms requiring occasional treatment such as dilatation or antidiarrheal medication) in 25 (27%), and poor (symptoms requiring regular treatment) in 2 (2%). Subjective assessment of functional results (patient satisfaction) was also recorded: 88% of patients were pleased with the outcome of the operation, 93% reported feeling better than before the operation, and 96% would choose to undergo the operation again with their knowledge of the outcome.

	Comment

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Since our 1989 initial reported experience with esophageal resection for achalasia in 26 patients [4], as was predicted then, there has been an increasing number of patients presenting either primarily with severe end-stage disease (characterized by a tortuous megaesophagus) or secondarily with recurrent symptoms after prior esophageal intervention. Treatment of this group of patients is particularly challenging. Our approach has been to offer esophagectomy to patients who are least likely to benefit from nonresectional therapy. A key determinant in making this decision is the stage of the patient’s achalasia. We do not propose esophagectomy for every dilated achalasic esophagus 6 cm or more in diameter. If the axis of the esophagus is still straight, an esophagomyotomy will provide good relief of dysphagia and will allow the esophagus to empty by gravity. Alternatively, with a sigmoid-shaped megaesophagus of end-stage achalasia, esophageal retention may occur in the tortuous supradiaphragmatic segment and interfere with emptying even after an adequate esophagomyotomy. In such patients, the megaesophagus is a functionless organ that is a potential source of ongoing retention esophagitis, regurgitation with tracheobronchial soilage, and development of carcinoma in up to 3% to 10% [5–7]. In South America, where the experience with achalasia due to Chagas disease is far greater than in this country, Pinotti and colleagues [8] have recommended transhiatal esophagectomy for advanced cases characterized by a tortuous megaesophagus, whereas esophagomyotomy is the treatment for those with a moderately dilated but "straight" esophagus. Although laparoscopic myotomy has been recommended by some as initial treatment for patients with a sigmoid-shaped achalasic esophagus [9], in our experience myotomy has not provided as reliable relief of dysphagia for these individuals. Moreover, we have found that multiple prior esophageal operations are associated with a poorer functional outcome after esophagectomy, with those patients who have had multiple unsuccessful operations being less satisfied with the results after esophagectomy. For these reasons, we advise esophagectomy as primary therapy for those patients with the most advanced stages of achalasia.

Patients presenting with recurrent obstructive symptoms after prior myotomy or dilatation demand careful evaluation. Those who have failed dilatation therapy should be considered for esophagomyotomy. In patients with persistent or recurrent obstructive symptoms after esophagomyotomy, the etiology of treatment failure is variable: an inadequate myotomy, healing of the myotomy, the development of reflux esophagitis and stricture, obstruction from a concomitant fundoplication, an incorrect diagnosis, the development of carcinoma, or the development of a paraesophageal hiatal hernia. In those patients manifesting persistent dysphagia almost immediately after esophagomyotomy, it is likely that all of the obstructing fibers of the lower esophageal sphincter were not divided at the initial procedure, and reoperation to complete the myotomy will likely be successful. Alternatively, a reflux stricture may develop years after an initially successful esophagomyotomy with or without an antireflux procedure, and such a stricture does not respond well to dilatation therapy combined either with treatment with proton-pump inhibitors or the addition or revision of an antireflux procedure; the atonic esophagus simply empties poorly in the presence of a stricture. Many reoperative procedures have been proposed for recurrent achalasia: repeat esophagomyotomy; myotomy plus antireflux procedure; takedown or revision of prior fundoplication; antireflux procedure alone; Heineke-Mikulicz type cardioplasty; Thal-Hatafuku procedure; vagotomy, antrectomy, Roux-en-Y gastrojejunostomy; distal esophagectomy with intrathoracic esophagogastrostomy; and esophageal resections of varying extent with reconstruction with stomach, colon, or jejunum. However, when the results of the various reoperative procedures are assessed, acceptable results have been achieved in only 40 to 75% and for variable time periods [10]. Ellis and associates reported that only two thirds of patients undergoing repeat myotomy benefited from the procedure, and even poorer results were obtained after fundoplication for reflux symptoms [11]. It is our opinion that if a repeat esophagomyotomy is unsuccessful in one third of patients undergoing reoperation, a thoracic esophagectomy and cervical esophagogastric anastomosis represents a much more reliable option.

Our experience indicates that a transhiatal esophagectomy and a cervical esophagogastric anastomosis is safe and effective therapy in most patients requiring esophageal resection for either benign or malignant disease [12]. Watson and associates [13] recently reported 105 patients undergoing esophageal replacement for benign disease. They used colon as the esophageal replacement of choice in 85% of their patients, citing long-term complications associated with the use of a gastric conduit. In our experience, however, the functional results of esophageal substitution with stomach are better and more reliable than with colon, and problematic late redundancy of the esophageal conduit is not seen. Further experience with the vagal-sparing esophageal resection they recommend may obviate some of the troublesome postoperative morbidity in these patients. Young and associates [14] also reported a large series of patients undergoing esophagectomy for benign disease. These investigators used a variety of approaches for resection and reconstruction and found no significant association between the surgical approach and incidence of complications, with the exception of the use of a long substernal or subcutaneous conduit that was related to an increased incidence of anastomotic leak. The authors noted that the use of a cervical anastomosis was associated with a poorer functional result. In our experience, the routine use of a cervical anastomosis has provided very good results, especially if an anastomotic leak can be avoided.

A transhiatal approach is generally feasible even after prior surgical intervention. However, certain unique technical aspects of esophagectomy in the achalasic patient bear emphasis. First, deviation of the megaesophagus into the right chest is common and often results in entry into the pleural cavity during the esophageal mobilization. This is readily recognized and managed with tube thoracostomy. Second, the hypertrophied esophageal muscle of achalasia may be nourished by similarly hypertrophied thoracic esophageal aortic branches that require particular care in achieving hemostasis. Mediastinal exposure can be enhanced by the use of narrow, deep retractors placed on either side of the hiatus or by the splitting of the anterior diaphragm as described by Pinotti and colleagues [8]. During the esophagectomy, every effort should be made to directly, visualize, clamp, and ligate accessible mediastinal vessels. In practice this has been achieved in most cases. However, 2 patients did develop delayed mediastinal bleeding from uncontrolled arterial branches in the esophageal bed and required thoracotomy for control. Third, the esophageal dilation frequently extends to the level of the thoracic inlet and makes mobilization of the cervical esophagus more difficult. Extra care must be taken to completely encircle the cervical esophagus without injuring the recurrent laryngeal nerves or the esophagus. We have not seen an increased incidence of recurrent laryngeal nerve injury in this series. Fourth, the exposed esophageal submucosa after prior esophagomyotomy typically becomes adherent to the adjacent aorta and left lung, complicating transhiatal mobilization. Some authors have recommended transthoracic esophageal resection in these patients as the preferred approach for this very reason [15]. Although we agree that such adhesions do present a challenge, in our experience the dissection generally can be performed through the hiatus with nearly uniform success. Care must be taken to dissect the esophageal submucosa away from the adjacent aorta under direct vision, even at the risk of entering the esophageal lumen, which may actually help to clarify the appropriate plane of dissection. Earlier in our experience, dense adhesions required a thoracotomy to complete the mediastinal dissection in 6 of our patients. If the lumen is entered during esophageal mobilization, soilage of the mediastinum is reduced by prompt suture closure and thorough mediastinal irrigation after removal of the esophagus. Fifth, apparent generalized parasympathetic dystrophy in some achalasic patients appears to result in more severe postvagotomy dumping symptoms than occur in others after transhiatal esophagectomy. In such cases, if a high-fiber "antidumping" diet and standard antidiarrheal medication are ineffective, Somatostatin injections may be required for control. These patients should therefore be warned preoperatively of the possibility of postoperative dumping symptoms, which in most cases are self-limited and dissipate.

We conclude that carefully selected patients with end-stage achalasia or achalasia with recurrent obstructive symptoms benefit from transhiatal esophagectomy and a cervical esophagogastric anastomosis. We believe that the safety, reliability, and clinical efficacy of this approach has been documented.

	Acknowledgments

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We thank Seema S. Sonnad, PhD, Assistant Professor, Department of Surgery, University of Michigan and Associate Director, Consortium for Health Outcomes, Innovation, and Cost Effectiveness Studies, who provided statistical consultation for this manuscript.

	Discussion

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DR D’AMICO: Doctor Devaney, I think that was an excellent presentation and I admire your results. I have questions about three of the complications.

Number one, the 46% dilatation rate seems a little high. I appreciate your honesty in reporting that, but it seems a little high, greater than the 33% that we usually see in the Michigan series for carcinoma. Do you think the achalasia has anything to do with that, or among these technical issues that you’re looking at, are you going to address that?

Number two, it’s relatively easy to clear the dilated esophagus from the upper thorax in cases like this. What was the etiology of the tracheal injury?

Number three, your explanation about the increased dumping, is that speculative about the excess parasympathetic tone, or is there any data or evidence in the literature that would support that?

Again, I thought that was an excellent paper.

DR DEVANEY: Thank you for your comments.

With regard to the rate of dilatation, I think in our practice we generally will dilate anyone who comes in and says that there is any sticking of anything at all. So I think our policy has just been so liberal. I’m not sure that there is really going to be a significant difference from the rest of our patients who have been treated with transhiatal esophagectomy for malignant disease, and I don’t believe that there is anything particular with regard to the achalasic esophagus that would lead to a higher stricture rate.

With regard to the tracheal injury, there was one incidence of a tracheal injury that was managed without much difficulty. I don’t have a lot of details on that complication to share with you today.

And the third question that you referred to regarding my comment regarding the excessive postvagotomy dumping symptoms that we had, it’s anecdotal. We don’t have any definite data supporting this, although a lot of these patients did have evidence of some preoperative parasympathetic dystrophy; but, again, I don’t have any specific data to share with you today on that.

DR ORRINGER: In answer to some of the questions that were just raised, the 1 patient who had a tracheal injury had a membranous tear that was exposed through a partial upper sternal split and repaired without difficulty after removal of the esophagus. We have noted that a few of our achalasic patients seem to have a generalized parasympathetic dystrophy, and I would be interested to hear if anybody else dealing with these patients has seen this. Some of these patients (for example, with minimal manipulation in the chest or with opening the rib spreader soon after induction of general anesthesia) will become bradycardic. Or when the drapes are removed at the end of the case, there is evidence of excessive salivation. And for some reason, while for most patients who develop dumping symptoms after esophagectomy, the problem is generally mild, easily managed, and dissipates within 6 to 12 months, some of our achalasic patients have developed the worst of the worst dumping I’ve ever seen after esophagectomy, and they have had to go to somatostatin injections for relief. It is purely conjectural in answer to the question, but it seems that we are dealing with a true parasympathetic neurologic abnormality in some of these patients. And we tell the patients preoperatively that they may experience excessive diarrhea.

DR DEVANEY: Just as a follow-up, I would like to say that I think the advent of the vagal-sparing esophagectomy may provide some interesting data in the future for these patients.

DR SCOTT J. SWANSON (Boston, MA): I also thought that was an excellent series.

We haven’t seen the number you have, but we have been plagued by reflux and even aspiration using the stomach in these patients, and I wonder if the reason you’re seeing the higher incidence of stricturing could be that you’re seeing more reflux than you appreciate. When we see late benign strictures after esophageal resections for cancer, it’s usually because of reflux. Have you considered this?

Thanks.

DR DEVANEY: I suppose it is a possibility, but, again, in our patients we have pretty careful follow-up and we’re really sensitive to any symptoms of reflux, heartburn, etc. Most of the strictures that we have seen have occurred early on in relation to anastomotic leaks. I don’t think we’ve done 24-hour pH monitoring in these patients, so I can’t give you detailed information on the amount of reflux that they are having, but my suspicion is that the stricture rate or the dilatation rate is not due to reflux.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 

1. Orringer M.B., Sloan H. Esophagectomy without thoracotomy. J Thorac Cardiovasc Surg 1978;76:643-654.[Abstract]
2. Orringer M.B. Transhiatal esophagectomy without thoracotomy. In: Orringer M.B., Zuidema G.D., eds. Shackelford surgery of the alimentary tract, 4th ed, vol I: the esophagus. Philadelphia: WB Saunders, 1996:414-445.
3. Orringer M.B., Marshall B., Iannettoni M.D. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-288.[Abstract/Free Full Text]
4. Orringer M.B., Stirling M.C. Esophageal resection for achalasia: indications and results. Ann Thorac Surg 1989;47:340-345.[Abstract]
5. Hankins J.R., McLaughlin J.S. The association of carcinoma of the esophagus with achalasia. J Thorac Cardiovasc Surg 1975;69:355-360.[Abstract]
6. Peracchia A., Segalin A., Bardini R., Ruol A., Bonavina L., Baessato M. Esophageal carcinoma and achalasia: prevalence, incidence and results of treatment. Hepato-Gastroenterology 1991;38:514-516.[Medline]
7. Streitz J.M., Jr, Ellis F.H., Jr, Gibb S.P., Heatley G.M. Achalasia and squamous cell carcinoma of the esophagus: analysis of 241 patients. Ann Thorac Surg 1995;59:1604-1609.[Abstract/Free Full Text]
8. Pinotti H.W., Cecconello I., da Rocha J.M., Zilberstein B. Resection for achalasia of the esophagus. Hepato-Gastroenterology 1991;38:470-473.[Medline]
9. Patti M.G., Feo C.V., Diener U., et al. Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc 1999;13:843-847.[Medline]
10. Fekete F., Breil P., Tossen J.C. Reoperation after Heller’s operation for achalasia and other motility disorders of the esophagus: a study of eighty-one reoperations. Int Surg 1982;67:103-110.[Medline]
11. Ellis F.H., Jr, Crozier R.E., Gibb S.P. Reoperative achalasia surgery. J Thorac Cardiovasc Surg 1986;92:859-865.[Abstract]
12. Orringer M.B., Marshall B., Iannettoni M.D. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999;230:392-403.[Medline]
13. Watson T.J., DeMeester T.R., Kauer W.K., Peters J.H., Hagen J.A. Esophageal replacement for end-stage benign esophageal disease. J Thorac Cardiovasc Surg 1998;115:1241-1249.[Abstract/Free Full Text]
14. Young M.M., Deschamps C., Trastek V.F., et al. Esophageal reconstruction for benign disease: early morbidity, mortality, and functional results. Ann Thorac Surg 2000;70:1651-1655.[Abstract/Free Full Text]
15. Miller D.L., Allen M.S., Trastek V.F., Deschamps C., Pairolero P.C. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995;60:922-926.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Mark D. Iannettoni Mark B. Orringer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Devaney, E. J. Articles by Marshall, B. Search for Related Content PubMed PubMed Citation Articles by Devaney, E. J. Articles by Marshall, B. Related Collections Esophagus - other