Esophageal resection and reconstruction in patients with primary or secondary motility disorders of the esophagus are very uncommon. Often, consideration of esophagectomy is the final decision in a long and difficult plan of care by both the gastroenterologist and esophageal surgeon. Fortunately, the majority of motility disorder patients are seen in expert centers, where they usually undergo extensive evaluation and are treated appropriately with reasonable palliation of their symptoms.1 Patients who are not well palliated usually present with disabling symptoms associated with obstruction or pseudo-obstruction, uncontrollable pain with eating, and/or refractory gastroesophageal reflux disease. In addition, these patients may have undergone not one but several prior esophageal and/or gastroesophageal surgeries.
Esophagectomy in these situations is viewed as a “Hail Mary” and may not be given enough credit owing to the significant risk of mortality and morbidity that have been attributed to this operation. However, recent technical improvements have lessened these risks, and perhaps esophagectomy should be considered earlier in the treatment course rather than after repeated attempts at repair. In skilled hands, the improvement in quality of life (QoL) and swallowing function after esophagectomy may outweigh the risks of the operation for many of these patients.
This chapter briefly reviews the features, initial treatment(s), complications of treatment, and long-term outcomes of the most common primary and secondary motility disorders. It outlines the indications for esophagectomy, discusses current controversies in management, describes the technique of vagal-sparing esophagectomy (VSE) for reconstruction in these settings, and finally, summarizes the outcomes of esophagectomy in patients with benign disease.
PRIMARY AND SECONDARY MOTILITY DISORDERS
Detailed review of the primary and secondary motility disorders is beyond the scope of this chapter. For meaningful discussion of the role of esophagectomy, however, it is helpful to have some idea of the salient features of the most common primary and secondary motility disorders, as well as the recommended diagnostic evaluation, manometric findings, appropriate primary surgical therapy, and long-term complications. This information is summarized in Table 36-1.
Table 36-1FEATURES, TREATMENT, AND LONG-TERM COMPLICATIONS IN NAMED MOTILITY DISORDERS1 |Favorite Table|Download (.pdf) Table 36-1FEATURES, TREATMENT, AND LONG-TERM COMPLICATIONS IN NAMED MOTILITY DISORDERS1
| ||FEATURES ||PRIMARY SURGICAL TREATMENT ||LONG-TERM COMPLICATIONS |
|Achalasia || |
Dysphagia, regurgitation, and heartburn
EGD, barium swallow, manometry
Aperistalsis, absent or incomplete LES relaxation or type I classic with minimal pressure, type II compression, or type III spastic
Laparoscopic modified Heller myotomy and partial fundoplication
Relief of symptoms in >90% at 5 years, and in 73% at 16 years.
POEM, relief of symptoms in >97% at 1 year, and in >88% at 3 years.
|Diffuse or Segmental Esophageal Spasm |
Dysphagia and/or chest pain
EGD, barium swallow, manometry, pH, cardiac studies
Normal peristalsis interrupted by simultaneous contractions in >20%, hypertensive LES (50%), abnormal LES ...