Esophagectomy for achalasia: Patient selection and clinical experience

Background. In 1989, we predicted an increasing number of esophagectomies f or megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challe nging, as the potential operative morbidity of an esophagectomy must be wei ghed 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 a chalasia during the past 20 years were reviewed retrospectively and the res ults of operation assessed using our prospectively established Esophageal R esection Database and follow-up information obtained through personal conta ct with the patients. Results. Patient age averaged 51 years. Indications for esophagectomy inclu ded tortuous megaesophagus (64%), failure of prior myotomy (63%), and assoc iated 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 leng th of stay averaged 12.5 days. Major complications included anastomotic lea k (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleedin g requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital d eaths (2%) from respiratory insufficiency and sepsis. Follow-up has average d 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% hav e refractory postvagotomy dumping. Conclusions. Esophagectomy, preferably through a transhiatal approach, is g enerally safe and effective therapy in selected patients with achalasia. Un ique technical considerations include difficulty encircling the dilated cer vical esophagus, deviation of the esophagus into the right chest, large aor tic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy. (C) 2001 by The Society of Thora cic Surgeons.