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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Manoel Ximenes, III Daniel L. Miller Mark S. Allen Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ximenes, M. Articles by Allen, M. S. Search for Related Content PubMed PubMed Citation Articles by Ximenes, M., III Articles by Allen, M. S.

Ann Thorac Surg 1996;62:322-323
© 1996 The Society of Thoracic Surgeons

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Correspondence

Esophageal Resection for Recurrent Achalasia

Thoracic Surgery Unit Hospital de Base of the Distrito Federal Brasilia, DF, Brazil

To the Editor:

I read with much attention and interest the article by Miller and associates [1]. They reported on 37 patients from whom they removed the esophagus as a remedial operation due to recurrence of symptoms after the initial procedure for the treatment of achalasia. In this group of patients they had two intraoperative deaths (5.4%) and twelve complications (32.4%), including cardiac dysrhythmia, cervical anastomosis leak, transient vocal cord paralysis, pulmonary embolus, and one reexploration for bleeding.

I would like to take issue with this type of approach and report our results with a much less aggressive surgical treatment. In a group of 210 patients with advanced achalasia due to Chagas' disease in whom we performed a cardioplasty with an endoluminal valve, 17 were undergoing reoperations [2]. In this group of patients we had neither mortality nor morbidity [3]. In a collected series of 755 patients who had this type of cardioplasty, as described by Thal in 1965, reported in the Brazilian literature, we found a mortality rate of 0.32%, morbidity of 4.72%, and good to excellent results in 91.2% [4–6].

In our initial report of 450 patients treated for this condition, 40 had the esophagus removed through the chest. In this subset of patients we had a mortality rate of 7.5% and good results in only 75% [4]. In cases of perforation due to pneumatic dilatation the cardioplasty offers the same good results as if performed on elective basis [5].

We realize that of the host of 45 procedures already described to treat this condition none is satisfactory [6]. However, we should never forget that this is a benign disease and its treatment should be kept simple and straightforward, with minimal morbidity and mortality, even in cases of recurrence as described by Miller and associates.

I compliment the Mayo group on another complete and most rewarding article about this simple but at times distresssing disease.

References

1. Miller DL, Allen MS, Trastek VF, Deschamps C, Pairolero PC. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995;60:922–34.[Abstract/Free Full Text]
2. Ximenes M. Chagas' disease of the esophagus. In: Shields TW, ed. General thoracic surgery. Philadelphia: Williams & Wilkins, 1994:1538–69.
3. Ximenes M. Chagas' disease. In: Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr, eds. Esophageal surgery. New York: Churchill Livingstone, 1995:443–57.
4. Ximenes M, Silva RO, DeBiase H, et al. Primary surgical treatment of Chagas' megaesophagus. Results of 450 cases. HFA Pub Tec Cient 1987;2:147–61.
5. Ximenes M. Ruptured Chagas' megaesophagus. Surg Gynecol Obstet 1989;168:263–74.
6. Ximenes M. Megaesophagus. Current review of techniques and results. Rev Saude DF 1991;2:207–36.

Reply

Division of Cardiothoracic Surgery University of Louisville School of Medicine 201 Abraham Flexner Way Suite 1200 Louisville, KY 40202
Section of Thoracic Surgery Mayo Clinic 200 First St, SW Rochester, MN 55905

To the Editor:

We thank Dr Ximenes for his comments regarding our article [1]. We recognize his surgical expertise in the treatment of achalasia secondary to Chagas' disease. However, we think he has misinterpreted our article. The basis of our article was to present follow-up information on patients who required esophageal resection as a reoperative procedure for achalasia. We tried to examine which procedures should be performed to minimize operative morbidity and mortality and improve long-term functional results. From our retrospective review, we concluded that transhiatal esophageal resection for recurrent symptoms or complications after initial surgical treatment for achalasia was associated with increased morbidity and mortality. We believe that when esophageal resection is required after initial surgical treatment has failed, direct visualization of the esophagus should be performed transthoracically. In our group of patients who underwent transthoracic esophagectomy, there were no operative deaths. Only 8.2% of our patients who required surgical intervention for treatment of their achalasia underwent esophageal resection. None of these resections were done as the initial treatment. Doctor Ximenes and associates [2] reported a mortality rate of 7.5% in 40 patients who underwent primary surgical treatment of achalasia secondary to Chagas' disease. We consider this a high mortality rate for initial therapy of benign disease.

We concur with Dr Ximenes that the treatment of these patients should be kept simple; however, when esophageal resection is required as a reoperative procedure it should be performed via a transthoracic approach to minimize complications in this group of patients.

References

1. Miller DL, Allen MS, Trastek VF, Deschamps C, Pairolero PC. Esophageal resection for recurrent achalasia. Ann Thorac Surg 1995;60:922–34.
2. Ximenes M. Ruptured Chagas' megaesophagus. Surg Gynecol Obstet 1989;168:263–74.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Manoel Ximenes, III Daniel L. Miller Mark S. Allen Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ximenes, M. Articles by Allen, M. S. Search for Related Content PubMed PubMed Citation Articles by Ximenes, M., III Articles by Allen, M. S.