Ann Thorac Surg 2005;79:749
© 2005 The Society of Thoracic Surgeons
Correspondence
Surgical Therapy for End-Stage Achalasia
Joseph H. Gorman, III, MD,
Robert C. Gorman, MD,
Emest F. Rosato, MD
Department of Surgery, Hospital of The University of Pennsylvania, 3400 Spruce St, 6 Silverstein, Philadelphia, PA 19104, USA
gormanj{at}uphs.upenn.edu
To the Editor:
Hsu and colleagues [1] presented a cohort of 8 patients with end-stage achalasia who had undergone unsuccessful esophagomyotomy in the distant past. All patients were treated with cardiectomy, distal esophagectomy, and replacement with a short-colon interposition using a left thoracoabdominal incision. The authors suggested that this approach relieves the esophageal obstruction with less morbidity than total esophagectomy through a right thoracotomy or a transhiatal approach.
Neglected or inadequate surgical treatment of achalasia can result in the megaesophagus syndrome. Some esophageal surgeons [2, 3] believe the best remedial operation for this condition is total esophagectomy, whereas others [4], including Hsu and associates, favor less extensive procedures. The authors demonstrated both subjectively (patient questionnaire) and objectively (barium swallow) that their approach can improve swallowing. However, the claim that their operation is less morbid does not seem to us to be supported by their data and the modern literature on this topic.
To justify their approach, the authors made reference to a 2001 report by a group [2] from The University of Michigan reporting a complication rate of 30% in 93 patients with achalasia who underwent total esophagectomy. Hsu and co-workers they suggested that this degree of morbidity is excessive and can be limited by using their method. Although daunting, a 30% complication rate is within the accepted range of morbidity when all patients undergoing total esophagectomy are considered [5–7] and is very similar to the complication rate reported by the authors for their operation.
Most experienced esophageal surgeons would agree with Hiebert and Bredenberg [8] that "the most critical determinant of morbidity [in esophageal operations] is the surgeon's proficiency based on a personal experience with the operation." As a result, there is little consensus regarding many aspects of the surgical treatment of esophageal pathological conditions. We respect the desire of Hsu and associates to present an alternative approach to a difficult clinical problem but question whether their procedure really is simpler for the surgeon and less morbid for the patient.
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References
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- Hsu H-S, Wang C-Y, Hsieh C-C, Huang M-H. Short-segment colon interposition for end-stage achalasia. Ann Thorac Surg. 2003;76:1706–1710[Abstract/Free Full Text]
- Devaney EJ, Iannettoni MD, Orringer MB, Marshall B. Esophagectomy for achalasia: patient selection and clinical experience. Ann Thorac Surg. 2001;72:854–858[Abstract/Free Full Text]
- Peters JH, Kauer WK, Crookes PF, Ireland AP, Bremner CG, DeMeester TR. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg. 1995;130:632–636[Abstract]
- Ximenes M. Chagas' disease. Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr. Esophageal surgery. New York: Churchill Livingstone; 1995. p. 443–457
- Birkmeyer JD, Stukel TA, Andrea E, et al. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349:2117–2127[Abstract/Free Full Text]
- Peters JH, Kronson JW, Katz M, DeMeester TR. Arterial anatomic considerations in colon interposition for esophageal replacement. Arch Surg. 1995;130:858–862[Abstract]
- Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surg. 2001;25:196–203[Medline]
- Hiebert CA, Bredenberg CE. Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr. Esophageal surgery. New York: Churchill Livingstone; 1995. p. 649
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