Ann Thorac Surg 2003;76:1706-1710
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Short-segment colon interposition for end-stage achalasia
Han-Shui Hsu, MDa,
Chien-Ying Wang, MDa,
Chih-Cheng Hsieh, MDa,
Min-Hsiung Huang, MDa*
a Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, National Yang-Ming University School of Medicine, Taipei, Taiwan
Accepted for publication May 12, 2003.
* Address reprint requests to Dr Huang, Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, No 201, Section 2, Shih-Pai Rd, Taipei, Taiwan.
e-mail: mhhuang{at}vghtpe.gov.tw
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Abstract
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BACKGROUND: The reoperative procedures for achalasia vary. Repeat esophagomyotomy with or without antireflux procedure and esophageal resection of varying extent with reconstruction using stomach, jejunum, or colon have been reported. In this series, we have retrospectively reviewed our experience and reported the results with limited distal esophagectomy and short-colon interposition in the treatment of patients with recurrent symptoms of achalasia after prior failed esophagomyotomy.
METHODS: Nine consecutive patients (5 men, 4 women; 27 to 74 years of age; mean, 52 years) with recurrent symptoms of achalasia and at least one failed prior esophagomyotomy underwent gastric cardiectomy, distal esophagectomy, and replacement with an at least 30-cm short-colon interposition through a left thoracoabdominal approach. Morbidity of the procedure and the length of hospital stay were recorded. The symptomatic evaluation, ability to have a meal, and overall patient satisfaction after the operations were assessed.
RESULTS: Follow-up results were available in 8 patients. One patient had intestinal strangulation with graft failure 3 days after operation. Takedown of the graft and end-to-side esophagogastrostomy were successful. There was no mortality. Outcome assessment was completed at a median of 6 years (range, 1 to 12 years). Overall patient satisfaction was good in 6 patients, and fair and worse in 1 patient each. Most of the patients could have regular meals. Two patients had intermittent abdominal fullness after meals. Six of these 8 patients would have the operation again.
CONCLUSIONS: Limited distal esophagectomy with short-colon interposition through a left thoracoabdominal approach is a safe and feasible alternative to near total esophagectomy in patients with achalasia who have prior failed esophagomyotomy. Improved alimentary function was observed in most of the patients after operation, which resulted in a better quality of life.
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Introduction
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The treatment of esophageal achalasia remains controversial, and all therapies to relieve the symptoms are considered to be palliative. Modification of the original Heller's operation consisting of a single anterior esophagomyotomy was reported by Zaaijer [1], which now remains the standard surgical approach for achalasia. Nonetheless, symptoms may recur in some patients with prior esophagomyotomy. The causes for the recurrent symptoms include inadequate myotomy, healing of the myotomy, the development of reflux esophagitis, and incorrect diagnosis [2, 3]. The reoperative procedures for achalasia vary. Ellis and colleagues [4], who enrolled 46 patients with esophageal achalasia who underwent reoperation, concluded that for good results to be achieved after reoperative procedures the preoperative diagnosis must be accurate, and the operation should be performed before the development of megaesophagus. The best results in their study were obtained by takedown of a previous wrap and resective procedures [4]. Some authors had also suggested that extensive esophagectomy should be considered to relieve the esophageal obstruction and restore normal alimentation in patients with megaesophagus or prior esophagomyotomy [5–7]. However, the operative risk and complication were inevitably higher when extensive esophageal resection with reconstruction was performed. Orringer and Stirling [5] reported their experience in 1989 of management of patients with achalasia who had previous esophagomyotomy and megaesophagus. Twenty-four transhiatal esophagectomies and two transthoracic esophagectomies were performed, with the intraoperative blood loss averaging 765 mL. In 1995, Miller and coworkers [6] concluded, in their series consisting of 37 patients who underwent esophageal resection after initial surgical treatment for achalasia, that transhiatal resection was associated with increased morbidity and mortality. Peters and colleagues [7] advocated esophageal resection through right thoracotomy with colon interposition for patients with end-stage achalasia. However, this three-hole procedure was also associated with high morbidity. Four of 19 patients (21%) had complications. The rationale for performing limited distal esophageal resection for patients with achalasia who had prior failed esophagomyotomy is to resect the wrapped esophagogastric junction that causes obstructive symptoms in the patients and to interpose a patent short colon. Left thoracoabdominal approach provides an excellent operative field to carry out the procedure. The advantages include lesser dissection of the intrathoracic esophagus and easy mobilization of the wrapped esophagogastric junction. In this series, we have retrospectively reviewed our experience and reported the results with limited distal esophagectomy and short-colon interposition through a left thoracoabdominal approach in the treatment of the patients with recurrent symptoms of achalasia after prior failed esophagomyotomy.
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Material and methods
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From 1990 to 2002, we performed limited distal esophagectomy and cardiectomy with short-colon interposition in 9 consecutive patients with achalasia in whom prior esophagomyotomy failed to relieve the symptoms. The clinical information is shown in Table 1.
Five men and 4 women were included in this study, with ages varying from 27 to 74 years (average age, 52 years). The manometric study was available in 5 patients, who all showed high resting pressure and incomplete relaxation of lower esophageal sphincter. Simultaneous contraction of lower esophageal body in the swallow test was seen in 4 patients, and aperistalsis occurred in 1 patient. The indications for the limited esophageal resection included intractable recurrent symptoms after prior esophagomyotomy and dilated esophagus shown in esophagogram (Fig 1).
Six patients had previous esophagomyotomy in other hospitals. Six patients had one transthoracic esophagomyotomy for achalasia, and 3 patients had two esophagomyotomies before this presentation. The interval between the two esophagomyotomies in these 3 patients ranged from 6 to 10 years and averaged 7 years. The interval between the last esophagomyotomy and the limited distal esophagectomy with short-colon interposition in all patients ranged from 1 to 40 years and averaged 17 years. No patients had received pneumatic dilation or Botox injections before operation.
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Fig 1. Radiographic features of 2 patients with prior esophagomyotomy demonstrating markedly dilated esophagus.
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Operative procedure
A left thoracoabdominal incision was made. The chest was entered through the sixth intercostal space. The diaphragm was divided near the insertion to obtain better exposure. The distal esophagus was mobilized until the level of the inferior pulmonary ligament. The esophagogastric junction was freed from the hiatus. Short gastric vessels were divided and ligated. A cardiectomy along with a distal esophagectomy was performed. An at least 30-cm left colon with the pedicle based on the left colic artery was mobilized and interposed between the distal esophagus and the stomach. The intraabdominal portion was about 15 cm in length to decrease the incidence of reflux. An end-to-end esophagocolonic anastomosis was performed at the level of the inferior pulmonary vein using two-layer interrupted sutures. The gastrocolic anastomosis was made at the posterior wall of the stomach. Pyloroplasty was performed in all patients.
The morbidity of the procedure and length of hospital stay were reviewed. All patients were interviewed by the same surgeon by telephone contact using a questionnaire focusing on the ability to ingest a meal, the symptoms related to alimentation, and overall patient satisfaction with the outcome of surgery (Table 2).
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Results
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Follow-up results were available in 8 patients. One patient had intestinal strangulation with graft failure 3 days after the operation. Takedown of the graft and end-to-side esophagogastrostomy was successful. Two other patients had minor complications including wound infection and prolonged endotracheal intubation in each patient, respectively. There was no mortality. The hospital stay ranged from 7 to 22 days, and averaged 15 days. All patients had esophagograms 6 months to 1 year after the operation, which showed smooth passage of the contrast medium. (Fig 2)
Outcome assessment was completed at a median of 6 years (range, 1 to 12 years). Six patients could have three regular meals a day. Two patients could have a soft rice diet mostly and sometimes a liquid diet after the operation. Two patients had intermittent abdominal fullness after meals. One patient had body weight loss and had severe abdominal fullness in the early postoperative period. Three patients needed antacid and prokinetic agents to help relieve the symptoms. Overall patient satisfaction was good in 6 patents, and fair and worse in 1 patient each. The patient who felt worse was a 72-year-old woman. She had prior esophagomyotomy 40 years before this operation, the longest interval between two operations in our series. Six of these 8 patients reported they would have the operation again.
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Fig 2. Postoperative esophagograms of 2 patients undergoing short-colon interposition for end-stage achalasia.
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Comment
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The pathophysiology of achalasia is destruction of the Meissner and Auerbach plexuses within the wall of the esophagus. The esophageal neural destruction and the absence of relaxation of the lower esophageal sphincter result in the classic radiographic alterations of a dilated esophagus with a tapering bird-beak narrowing of the distal end. The goal of treatment is to relieve the functional outflow obstruction, which can be accomplished by either a forceful dilatation or a surgical myotomy of the lower esophageal sphincter. A surgical myotomy performed before esophageal dilatation or tortuosity develop is associated with a long-term success rate of 90% [8, 9]. Even with the successful myotomy, some patients exhibited recurrent symptoms of dysphagia years later. Clinically, the esophagus would become markedly dilated and more tortuous, which necessitates resection to restore normal alimentation. Different approaches for esophagectomy in patients with end-stage achalasia had been reported [5–7, 10]. Orringer and Stirling [5] concluded that transhiatal esophagectomy provided the most reliable treatment of esophageal obstruction, pulmonary complications, and potential late development of carcinoma in the patient with a megaesophagus of achalasia or a failed prior esophagomyotomy. However, Miller and coworkers [6] from the Mayo Clinic group reported that transhiatal esophageal resection for recurrent achalasia was associated with increased morbidity and mortality. They recommended that transhiatal esophageal resection should be used with reservation in patients who have had multiple prior operations for achalasia. In the report of Devaney and colleagues [10], the average intraoperative blood loss was 672 mL, with a complication rate of 30% in 93 patients undergoing transhiatal esophagectomy for achalasia.
The ideal method of reconstruction after esophagectomy for benign disease remains controversial. Some advocated that gastric interposition was the procedure of choice for most patients with benign disease on the basis of needing only one anastomosis and having a feasible blood supply of the stomach when it is used as the esophageal substitute. However, other authors have suggested that the colon is the best conduit to restore swallowing function, mainly because of the disadvantage of having a greater potential for the aspiration of gastric juice or developing a high incidence of dysphagia when cervical esophagogastric anastomosis is performed [7, 11–14]. The advantage of limited distal esophagectomy through a left thoracoabdominal approach included lesser dissection of the intrathoracic esophagus and easy mobilization of the distal esophagus and the wrapped esophagogastric junction, which could be severely adherent and difficult to dissect owing to previous transthoracic esophagomyotomy. Reconstruction with short-colon interposition can be accomplished at the same time. In the series, most of the patients had an uncomplicated postoperative course. No postoperative pneumonia or leakage was encountered. Prolonged ventilatory support was needed in 1 patient who was 72 years old.
The main goal of the treatment for end-stage achalasia is to restore the normal alimentation of the patients. In 1988, DeMeester and associates [15] did excellent work in their study regarding the long-term functional results after colon interposition. Twenty-six of 34 patients who were interviewed after the operation volunteered to undergo some functional studies consisting of a fluoroscopically measured transit time of liquid barium, barium burger, and acidified liquid barium between the pharynx and the stomach. Young and colleagues [16] in 2000 reported their results of self-assessment of functional outcome and quality of life after esophageal reconstruction for benign disease. The long-term functional result was determined by a two-part questionnaire consisting of the self-assessment of esophageal function and quality of life. The scores were compared among the factors. Our functional evaluation was based on the questionnaire directed to assess the patient's eating habits, ability to swallow, and symptomatic side effects of the operation. The patients were also asked to give their own evaluation of the success of the operation. Six of these 8 patients felt improvement in eating after the operation. One patient felt there was no improvement after the operation. One patient felt even worse. We observed that this patient had the longest interval between prior esophagomyotomy and short-colon interposition in our series. Some thoracic surgeons were concerned about the use of short-colon interposition in patients with end-stage achalasia [17]. They pointed out that a poor outcome may be related to the nonfunctional, dilated residual esophagus and prolonged gastric emptying after vagotomy in this patient group, which may also account for the symptom of postoperative abdominal fullness in some of our cases.
Information regarding the peristaltic function of different esophageal substitutes after esophagectomy is scanty. Vagal-sparing esophagectomy can probably solve some problems associated with alimentary function encountered after transthoracic or transhiatal esophagectomy followed by reconstruction. Akiyama and coworkers [18] have suggested that a vagal-sparing procedure allows preservation of normal gastric function and avoids the long-term consequences of vagotomy. Banki and associates [19] recently evaluated the function of the vagal nerves and the gastric reservoir in 19 patients having vagal-sparing esophagectomy and colon interposition and found that the procedure preserved gastric secretory, motor, and reservoir function. They concluded that vagal-sparing esophagectomy is an ideal procedure for patients with end-stage benign disease, Barrett's esophagus with high-grade dysplasia, or esophageal carcinoma limited to the lamina propria.
Treatment for patients of end-stage achalasia with or without prior esophagomyotomy represents a challenge to the thoracic surgeon. The surgical procedures to restore alimentary function vary. Limited distal esophagectomy and cardiectomy with short-colon interposition through a left thoracoabdominal approach can be performed with minimal morbidity and acceptable palliative effect. Careful preoperative evaluation including the previous procedures, manometric study, and esophagogram is advised. Further investigation to compare the postoperative alimentary function among the procedures for the management of end-stage achalasia is advocated.
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References
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Abstract
Introduction
