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Ann Thorac Surg 2006;81:2049
© 2006 The Society of Thoracic Surgeons
Department of Surgery, Union Memorial Hospital, Suite 610, JPB 3333 N Calvert St, Baltimore, MD 21218-2895
(Email: richard.heitmiller{at}medstar.net).
The article by Gaissert and colleagues [1] represents a large series of patients treated by a very experienced group during 4 decades. The authors show that post-esophagomyotomy results are excellent in 91% of patients early after surgery, and that this outcome deteriorates to 61% of patients with long-term follow-up. Early postoperative dysphagia predicts late failure. The addition of fundoplication is not a significant predictor of outcome in their analysis. Finally, sigmoid esophagus is not an independent predictor of failure after esophagomyotomy. Therefore, esophagomyotomy, not esophagectomy with reconstruction, should be the first-line therapy for achalasia patients with sigmoid esophagus.
It is essential to maintain a lifelong perspective in treating achalasia, as patients present at a young age, and treatment is considered palliative. An ideal treatment option is safe, durable, and does not preclude further treatment options. Clearly the excellent results presented by Gaissert and colleagues [1] will serve as a benchmark to compare with other treatments, including minimally-invasive esophagomyotomy methods.
Optimal management of the subset of achalasia patients with sigmoid esophagus remains an unresolved issue. Gaissert and colleagues [1] argue that esophagomyotomy, not esophagectomy, should be the first line of surgical treatment, because transthoracic myotomy is safe and results are comparable with its use in patients without esophageal enlargement. The authors argue that replacing one aperistaltic conduit (i.e., the native esophagus) with another one (i.e., the stomach, colon, or jejunum) does not make sense and does not justify the risks involved. However, the authors' conclusions are based on results with 12 patients over 40(+) years, in which long-term data was available for only 11 years. In addition, the authors define sigmoid esophagus solely on the basis of size (i.e., diameter > 6 cm). In fact, in most achalasia patients, as the esophagus dilates (> 6 cm), it also lengthens and begins to twist and fold. It is this acquired luminal tortuosity, not luminal diameter, that renders an esophagus as "end-stage." A dilated, tortuous esophagus will not empty well even with esophagomyotomy, because of its shape. Esophageal replacement for end-stage achalasia can be performed safely and with good results. The report by Banbury and colleagues [2] is an example of this. There were no deaths in their series of 32 patients, and 83% were able to swallow with no or mild dysphagia. Eighty-seven percent felt better after esophagectomy. Median follow-up time was only 43 months; however, as shown in the current study, early failures predict long-term outcome. Furthermore, there is no reason to expect deterioration in the long-term swallowing result after esophagectomy.
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