Ann Thorac Surg 2005;79:749-750
© 2005 The Society of Thoracic Surgeons
Correspondence
Surgical Therapy for End-Stage Achalasia: Reply
Han-Shui Hsu, MD,
Min-Hsiung Huang, MD
Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Number 201, Section 2, Shih-Pai Rd, Taipei, Taiwan
hsuhs{at}vghtpe.gov.tw
To the Editor:
We thank Dr Gorman and colleagues for their concerns regarding the morbidity experienced by the patients in our article [1] (9 patients with end-stage achalasia who had prior failure of esophagomyotomy). According to Gorman and coauthors, we suggested that our approach for patients with end-stage achalasia and a previous failed esophagomyotomy can relieve the esophageal obstruction with less morbidity than total esophagectomy through a right thoracotomy or a transhiatal approach [2, 3]. Actually, our conclusion was that limited distal esophagectomy with short-colon interposition through a left thoracoabdominal approach is a safe and feasible alternative to nearly total esophagectomy in patients with achalasia in whom prior esophagomyotomy failed. We did not claim that the operation we performed was less morbid than total esophagectomy through a right thoracotomy or a transhiatal approach.
The complications we encountered in the series included one wound infection and one prolonged intubation, which were minor, and one intestinal strangulation, which may not have been technique related. Because of the small number of patients involved, we did not compare the morbidity with that in other reports.
We understand that the procedure of short-colon interposition through a left thoracoabdominal approach can require three anastomoses and pyloroplasty. The procedure itself would not be easy for the surgeon or for the patients. However, the advantages include less dissection of the intrathoracic esophagus and easy mobilization of the wrapped esophagogastric junction. There was no leakage noted in our patients. In their study, Devaney and co-workers [3] found that the exposed esophageal submucosa after prior esophagomyotomy typically became adherent to the adjacent aorta and left lung, thereby complicating transhiatal mobilization. They also mentioned that in their earlier experience, dense adhesions necessitated a thoracotomy to complete the mediastinal dissection in 6 of the patients.
There are many issues that need to be addressed in the management of this difficult medical problem. They include the questions of how to relieve the esophageal obstruction, which substitute should be used, whether the esophagus should be totally removed in this benign disease and when it should be done, and which surgical procedure can provide better alimentary function postoperatively. We also agree with Hiebert and Bredenberg [4] in their chapter on selection and placement of conduits in esophageal surgical procedures that "the most critical determinant of morbidity is the surgeon's proficiency based on a personal experience with the operation." In dealing with this benign but difficult disease, we are not suggesting that our procedure is simpler for the surgeon and less morbid for the patients than other procedures but merely that, although our experience is limited, we are satisfied with the results we have seen to date.
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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]
- 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/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]
- Hiebert CA, Bredenberg CE. Selection and placement of conduits. 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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