The need for esophageal replacement in patients with benign esophageal dysmotility is relatively uncommon. Esophagectomy carries a significant morbidity and mortality risk and should be considered very carefully before it is used in patients with “benign” disease. Nor do any of the methods of reconstruction restore the patient's esophagus to normal physiology and function. Even the best of outcomes usually are associated with some abnormality in swallowing, a potential for regurgitation and aspiration, and some sequelae secondary to division of both vagal nerves. There are no hard-and-fast criteria defining the indications for esophagectomy in these patients. The disabling symptoms that prompt a decision for resection and replacement are most commonly those associated with obstruction (e.g., dysphagia, regurgitation, and aspiration), unmanageable pain (e.g., odynophagia owing to esophageal spasm), and/or disabling gastroesophageal reflux. Furthermore, almost all these patients have undergone one or more previous operations to manage their original motor abnormality. Ultimately, the surgeon must conclude that there is little or no prospect of a satisfactory outcome with medical or surgical management other than resection and reconstruction. The assessment of operative risk and likely outcome is frequently complex and difficult and is commonly best made after a frank and realistic review with the patient.
Indications for esophagectomy are subdivided by pathology into primary and secondary motor disorders. The primary motor disorders include achalasia, diffuse esophageal spasm, and rare, ill-defined derangements of esophageal dysmotility. Achalasia is by far the most common indication for resection and reconstruction in the primary group. Secondary motor disorders that sometimes require resection and replacement include esophageal scleroderma and rare instances of severe and disabling loss of effective peristalsis as a consequence of gastroesophageal reflux disease (GERD). Chagas' disease, a parasitic infection that is endemic in South America, resembles achalasia in many ways but results in significantly different alterations of the esophageal wall.
Achalasia is inevitably a progressive and incurable disease. All therapy is at best palliative, and the results of surgical treatment continue to deteriorate with the passage of time. This observation is supported in a number of publications reporting long-term follow-up in series of patients managed by a short esophagomyotomy with or without the addition of an antireflux reconstruction.1–5
Long-Term Results of Esophagomyotomy
Ellis and colleagues reported long-term results in a large number of patients managed by a transthoracic short esophagomyotomy without antireflux reconstruction.6 At the end of 1 year, 91% of patients registered good to excellent results. However, when 57 of these patients were evaluated over the long term (median 13.6 years), only 67% still registered good to excellent outcomes. Ten percent were classified as poor. These failures largely presented with disabling dysphagia, which Ellis and colleagues attributed to the natural progression of achalasia over time.
Malthaner and colleagues reported on 22 patients with newly diagnosed achalasia managed at Toronto General Hospital by a transthoracic esophagomyotomy combined with a Belsey ...