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Ann Thorac Surg 2009;87:1558-1563. doi:10.1016/j.athoracsur.2009.02.078
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

The Risk of Esophageal Resection After Esophagomyotomy for Achalasia

Shady M. Eldaif, MDa, Christopher J. Mutrie, MDa, W. Caleb Rutledge, MSa, Edward Lin, DOb, Seth D. Force, MDa, Joseph I. Miller, Jr, MDa, Kamal A. Mansour, MDa, Daniel L. Miller, MDa,*

a Division of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
b Division of Gastrointestinal Surgery, Emory University School of Medicine, Atlanta, Georgia

Accepted for publication February 26, 2009.

* Address correspondence to Dr Daniel L. Miller, General Thoracic Surgery, Emory University Clinic, 1365 Clifton Road NE, Atlanta, Georgia 30322 (Email: daniel.miller{at}emoryhealthcare.org).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
Background: Esophagomyotomy is the mainstay of treatment for achalasia with proven long-term success. However, in patients with a significantly dilated esophagus, many advocate esophageal resection thus forgoing an esophagomyotomy. The purpose of this study is to determine the esophagomyotomy failure rate in patients with achalasia.

Methods: A retrospective review of all patients with achalasia who underwent an esophagomyotomy from 1996 to 2006; 272 patients were divided into three groups based on their preoperative degree of esophageal dilation for comparison. The endpoint for esophagomyotomy failure was persistent symptoms requiring any intervention.

Results: The preoperative characteristics were comparable except for the severely dilated esophagus patients who had a longer duration of preoperative symptoms. Group I (mild dilatation) had 162 patients with 7 failures requiring intervention. Group II (moderate dilatation) had 74 patients with 4 failures and group III (severe dilatation) had 36 patients with 5 patients requiring intervention. For the entire cohort, median follow-up was 37 months (range, 8 to 144 months). There was no statistically significant difference among the groups in the number of patients requiring reintervention. The overall esophagectomy rate was only 2%. However, there was a significantly higher (p = 0.02) esophagectomy rate in the severely dilated patients.

Conclusions: The degree of esophageal dilatation associated with achalasia does not influence the success of an esophagomyotomy. Of the entire patient population in this study, only 6 patients required an esophagectomy. The majority of patients with the most severely dilated esophagus did not require an esophagectomy. Esophagomyotomy should be the first treatment option for patients with achalasia no matter what the degree of esophageal dilatation.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
There is no cure for achalasia. Treatment of achalasia is aimed at alleviation of symptoms with the focus being on the dysfunctional lower esophageal sphincter. Treatment modalities for achalasia have changed considerably over the past 15 years with the advent of endoscopic, thoracoscopic, and laparoscopic technology [1]. Laparoscopic esophagomyotomy with a partial fundoplication has become the treatment of choice for patients with achalasia [2–4]. The majority of patients present early in their disease process with treatment successes greater than 90% [5]. Unfortunately, over 25% of patients do not seek treatment for their achalasia until their esophagus is near totally dysfunctional and severely dilated [6]. The best treatment for these patients is controversial. Esophagectomy has been the preferred method of treatment for patients with end-stage achalasia [7, 8], but more recently some authors have advocated performing a laparoscopic esophagomyotomy as first-line treatment [9–11]. The purpose of this study is to determine the esophagomyotomy failure rate in patients with a severely dilated esophagus in comparison with patients with milder forms of esophageal dilatation.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Between January 1996 and December 2006, a total of 272 patients with achalasia underwent esophagomyotomy within the Emory Healthcare System. After obtaining approval and patient consent waiver from our Institutional Review Board, the medical records were reviewed for the patient's demographics, symptoms prior to esophagomyotomy, previous treatments for achalasia including endoscopic botulinum injection, pneumatic dilation, previous esophagomyotomy or other surgical operations, and clinical follow-up. We also reviewed all available manometry and endoscopy records, which were mostly done at the referring facilities, as well as barium esophagrams.

Preoperative barium esophagrams were reviewed to determine the degree of esophageal dilation so that patients could be grouped for statistical analysis. Patients with normal to mild dilation (less than 4 cm in diameter) formed group I (mild; 162 patients). Patients with moderate dilation (4 cm to less than 6 cm in diameter) were included in group II (moderate; 74 patients), and group III (severe; 36 patients) encompassed all patients with greater than or equal to 6 cm dilatation of the esophagus. Failed surgical treatment was reported when the patient required either endoscopic or a reoperative procedure, which included redo esophagomyotomy or esophagectomy.

Symptom assessment was performed preoperatively and postoperatively, one month after surgery and annually thereafter. Symptoms of dysphagia, heartburn, chest pain, regurgitation, voice change, cough, and asthma were assessed using a four-point scale (0 = none; 1 = mild; 2 = moderate; 3 = severe). Patient satisfaction with the procedure and information on any follow-up procedures was also included in the assessment. Patients who were not seen for office visits were contacted and given the questionnaire by phone. Preoperative and postoperative symptom assessment data were complete in all of the severely dilated patients, which was the focus of this study. Statistical analysis was performed by 1-way analysis of variance and Student-Neuman-Keuls testing were used for all pairwise comparisons of the means obtained for the three groups. The p values less than 0.05 were considered significant.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
There were 272 patients who underwent an esophagomyotomy for achalasia; 150 patients (55%) were female; however, in group III (severe) significantly more patients (63%) were male (p < 0.046). The median age at time of presentation for surgical intervention was 48 years old (range, 17 to 84 years). The duration of symptoms varied but averaged 84 months (range, 6 to 480 months); group III (severe) patients had a significantly longer duration of pre-esophagomyotomy symptoms (120 months) compared with the other two groups (p = 0.02).The majority of patients presented with multiple symptoms. The most common presenting symptom was dysphagia which occurred in 263 (96%) patients, while reflux symptoms were present in 186 (68%) patients. Of interest, patients with increasing esophageal diameter had more reflux (80%) symptoms compared with 60% in mildly dilated patients. Weight loss was reported by 72 patients, of whom 38% had greater than 25 pounds of weight loss. Patient demographics and presenting symptoms are summarized in Table 1.


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  		Table 1 Demographic Data and Initial Presenting Symptoms Divided Into Patient Groups Based on Esophageal Diameter on Preoperative Barium Esophagograms
 
The most common treatment performed prior to an esophagomyotomy was pneumatic balloon dilatation; 139 (51%) patients had at least one dilatation, while 19 (7%) patients had three or more dilations. Endoscopic botulinum toxin injections were used in 27 (10%) patients. A previous esophagomyotomy was performed in only 20 (7%) patients; group III (severe) patients underwent a greater number of esophagomyotomies although this was not statistically significant. Only 78 of the total 272 patients (29%) underwent an esophagomyotomy as the initial treatment for their achalasia. Prior esophageal procedures are summarized in Table 2.


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  		Table 2 Previous Treatment Modalities for Each Patient Group
 
Today our surgical approach for patients with achalasia consists of a laparoscopic esophagomyotomy with a partial fundoplication. As for the approach of the esophagomyotomy in this series of patients, 90% were performed laparoscopically and 10% by a left thoracotomy approach. The most common procedure performed was a laparoscopic esophagomyotomy with a posterior Toupet fundoplication in 81% of cases. All of the thoracotomy patients underwent an esophagomyotomy and modified 2-row 2-stitch Belsey Mark IV repair. A laparoscopic esophagomyotomy without an antireflux procedure was performed in 28 patients (10%); 19 were redo esophagomyotomies with an existing fundoplication already in place and 9 were first time esophagomyotomies only, which was early in our experience. There was no statistical difference between the groups with regard to the surgical procedures performed. Table 3 summarizes the operative procedures.


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  		Table 3 The Different Procedures Performed Over the 10-year Period of This Study Within the Emory Healthcare System
 
The average time for presentation of recurrent symptoms after undergoing an esophagomyotomy was 33 months (range, 9 to 48 months). The most common recurrent complaint was dysphagia (98%). Sixteen patients (6%) underwent treatment for recurrent symptoms after esophagomyotomy at our institution and included endoscopic dilatation in 7, repeat esophagomyotomy in 3 and an esophagectomy in 6. More patients in the severely dilated patients required reintervention, but there was no statistical significant difference in treatment failures between the three groups. Group III (severe) patients had a significantly higher esophagectomy rate (8%) compared with the other groups (p = 0.02). Reinterventions are summarized in Table 4.


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  		Table 4 Reinterventions Performed for Recurrent Symptoms After Undergoing an Esophagomyotomy for Achalasia at Our Institution
 
In the 36 patients undergoing treatment for a severely dilated esophagus, symptoms improved in 30 patients (83%) after esophagomyotomy with greatest improvement in dysphagia and regurgitation rates. Six patients complained of dysphagia after esophagomyotomy, 5 had persistent dysphagia with no relief from the esophagomyotomy, and one had recurrent dysphagia 6 months after esophagomyotomy. Three of the patients who had persistent dysphagia underwent esophagectomy, while two of the three remaining patients were treated successfully with dilatation. Overall 32 of the 36 patients (89%) with most severely dilated esophagus had relief of their preoperative dysphagia with esophagomyotomy alone, with or without subsequent dilatation. The symptom assessment score dropped from severe preoperatively to none or mild after esophagomyotomy in these severely dilated patients. The 3 patients who underwent esophagectomy are also free of dysphagia but reflux is an issue. Only 1 patient (3%) in the severely dilated group has continued dysphagia but is able to maintain a satisfactory weight without difficulty. Therefore, 89% of the severely dilated patients were satisfied with their nonesophagectomy treatment and relief of dysphagia.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
In this paper, we presented a series of 272 patients who underwent an esophagomyotomy for treatment of achalasia in the laparoscopic era, with focus on outcomes for patients with a severely dilated esophagus in comparison with patients with mild to moderate esophageal dilatation. We observed that while the esophagectomy rate was higher in the severely dilated group, the majority of these patients had excellent outcome after esophagomyotomy and did not require subsequent esophageal resection. If a patient is never relieved of his or her symptoms after an esophagomyotomy then an esophagectomy is warranted. It is not correct to put a patient through multiple procedures (such as repeat esophagomyotomies and dilatations) to preserve a nonfunctioning esophagus, which increases the patient's risk of pulmonary aspiration and cancer development that can be up to 10% [12]. Almost 90% of the patients with a severely dilated esophagus had relief of their dysphagia with an esophagomyotomy alone with or without subsequent dilatation.

Some authors predict that there will be an increase in esophagectomy rates for achalasia patients because of failure of the laparoscopic technique. In a recent series from our institution with a mean follow-up of 11.2 years, 94% of patients were satisfied with their operation and dysphagia scores were similar to the scores at the short-term follow-up of 24 months; only 6% complained of severe dysphagia at 10 years compared with 43% at presentation [13]. Therefore, a laparoscopic esophagomyotomy is a durable procedure. The median follow-up in our series was a moderate 37 months; there may be more patients who require a redo esophagomyotomy or even an esophagectomy at a later date, but this is unknown at the present time.

Ellis and colleagues [14] reported that only two thirds of patients who underwent a repeat esophagomyotomy were improved. However, when esophageal resection was performed they reported symptomatic improvement in all patients. These authors concluded that an esophagectomy should be used in all patients who require reoperation for achalasia. When to proceed with an esophagectomy rather than to attempt another esophagomyotomy, in our experience, should be individualized. If evaluation demonstrates minimal evidence of an esophagomyotomy and the esophagus is mildly dilated, then repeat esophagomyotomy should be considered. However, if the esophagus is markedly dilated and an adequate esophagomyotomy has been performed, as judged by barium swallow and manometry, resection is a better treatment option. Finally, for those patients with two or more previously failed operations, resection is our treatment of choice. As seen in our series, 5 of the 6 patients who underwent an esophagectomy had failed at least two previous esophagomyotomies and multiple dilatations. This poor outcome was also seen in another series from Emory, that when patients had undergone multiple endoscopic treatments for achalasia prior to a laparoscopic esophagomyotomy the outcome was worse and the esophagomyotomy was associated with more complications [15].

The degree of esophageal dilation has raised many questions in surgeons' minds as to what initial surgery to perform on patients with the severely dilated esophagus. Our approach has been to offer an esophagectomy to patients who are least likely to benefit from nonresectional therapy. We do not propose esophagectomy for every patient who has an esophagus dilated more than 6 cm in size, especially if the long axis of the esophagus is still within midline. The debate comes full circle when a patient has a sigmoid-shaped or horizontal esophagus. Esophageal retention is extremely high with a horizontal esophagus segment and interferes with emptying even after a complete esophagomyotomy. In such patients this usually nonfunctional esophagus is a potential source of persistent esophagitis, regurgitation with pulmonary aspiration, and development of a carcinoma.

The traditional way to perform an esophagomyotomy in a sigmoid-shaped esophagus had been the transthoracic approach through the left chest, which makes it difficult to reduce the severely angulated esophagus [16]. This is one of the reasons why some thoracic surgeons have advocated resection of the sigmoid esophagus. However, approaching these patients laparoscopically has allowed excellent reduction of the horizontal esophagus to allow better drainage of these functionless conduits, thus preserving esophageal continuity. However, if the dilated horizontal esophagus is the result of multiple failed treatments then an esophagectomy is warranted. Mineo and Pompeo [10] supported this theory in their series, with excellent results in 12 of 14 patients who underwent a laparoscopic esophagomyotomy instead of esophagectomy, in patients with a sigmoid esophagus. Patti and colleagues [9] extended these recommendations further and showed that there were no differences in patient outcomes between a dilated and a sigmoid esophagus at 2 to 3 year follow-up and concluded that esophagomyotomy is a reasonable option even for the sigmoid-dilated esophagus patients. In this series, only 2 of 36 patients with the most severely dilated esophagus had the floppy sigmoid variety and they underwent a laparoscopic esophagomyotomy with good outcomes.

Limitations of this study include its retrospective design, small sample size of the patients with a severely dilated esophagus (36 patients), and lack of a gold standard outcome measure for a laparoscopic esophagomyotomy. Previous follow-up studies have used a variety of metrics to assess the treatment of achalasia. Our grading system has been consistently used for over 10 years; giving patients the exact same questionnaire that they received preoperatively is the most objective way to categorize the subjective concept of symptom severity. Although performing barium swallows and esophageal manometry on all patients would likely have detected some operative failures, this was not logistically feasible given the wide geographic distribution of our patient population in the 10 years after their operation. In addition, we feel that improvement in symptoms is the most important metric in achalasia treatment outcomes, and anatomic and functional surveillance in the asymptomatic patient is probably not necessary.

Further study is needed to define the durability of laparoscopic esophagomyotomy in patients with the most severely dilated esophagus to determine whether symptoms truly do return over time. Regardless, a laparoscopic esophagomyotomy remains the best treatment option for patients with achalasia. Despite persistence of symptoms in a minority of patients, long-term satisfaction with the procedure is excellent and requirement for additional procedures is uncommon. In counseling patients who are candidates for a laparoscopic esophagomyotomy, the durability of the operation as well as the likelihood of symptomatic relief are important factors to consider. Our data confirm the efficacy of a laparoscopic esophagomyotomy, and suggest that patients with a significantly dilated esophagus who achieve short-term symptom relief are likely to sustain this benefit long term. In addition, the operation was not more technically demanding, had no more complications, and resulted in just as good relief of dysphagia as in the achalasia patients with an earlier stage disease.

In conclusion, a laparoscopic esophagomyotomy proved highly effective in improving subjective symptoms and avoiding esophagectomy in patients with all degrees of esophageal dilatation. These improvements were long lasting and did not differ among groups. Although confirmation by larger prospective studies is warranted, the results achieved in this series lead us to conclude that an esophagomyotomy with a partial fundoplication should be considered the first treatment option in achalasia patients with any degree of esophageal dilatation.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR KEITH NAUNHEIM (St. Louis, MO): Congratulations to you, Dr Eldaif, and to your co-authors, and I do appreciate receiving the manuscript in advance. Your study represents one of the largest achalasia series to date and highlights both the extent and the frequency of dysphagia relief that can be achieved with surgical intervention. This study confirms the findings previously reported in studies both by Mineo and by Patti that the presence of megaesophagus is not in and of itself a good indication for recommending esophagectomy as first-line therapy. I am in complete agreement with their recommendation and yours that laparoscopic myotomy should be the first line of therapy in such patients, at least in the absence of multiple prior myotomies. I do have a few questions. First of all, while it would have been desirable to have objective documentation of success in these patients utilizing tests such as serial manometry or nuclear esophageal emptying scans, such tests are not always routinely obtained for practical reasons of cost and patient's reluctance. However, although quantitative symptomatic scoring was reported as being performed preoperatively and postoperatively, there was no statistical analysis of scores provided in that manuscript. I wonder if you and the authors can share with us any data regarding that quantitative analysis.

DR ELDAIF: Thank you for the question. As it pertains to the analysis and the quality scoring pre and post, this was actually completed for the megaesophagus patients. There were 36 patients. The number was insufficient to carry on any statistical analysis. On average, however, most patients did relate to us that they had satisfaction with their myotomy results and they were having less rates of dysphagia postoperatively.

DR NAUNHEIM: I wonder in light of your findings if you have been able to convince your GI colleagues to change their treatment algorithm to consider up-front referral of achalasia patients for surgical consideration instead of proceeding through the process of multiple dilations and Botox injections. Are you getting to see patients, at least the younger patients, up front instead of after multiple interventions?

DR ELDAIF: According to my mentors, actually they are seeing a trend towards having an increased number of patients with essentially treatments, virgin treatments, I guess, for their achalasia up to now compared to what we have in the study of only 30% that have presented and were treated initially with a myotomy. It is probably about double the number.

DR NAUNHEIM: Finally, just a couple of technical questions. In the manuscript you outline your operative procedures, and you say that you routinely take down the short gastric vessels. Many surgeons don't do that for a partial fundoplication, whether it is an anterior Dor or a posterior Toupet. Do you believe this to be a necessary step and why? The other technical question deals with the routine contrast swallow done on postoperative day one to rule out leak. I wonder if you really think that is cost effective? I think a number of people actually aren't doing that after their first 50, 100, or, in this instance, 250 cases. What is your incidence of leak and do you think you are using resources effectively? So, one question is the necessity of short gastric division and the other question deals with routine radiography.

I would like to once again congratulate you. You did very well on the paper. I hope you do as well on this last answer. And I would like to thank the Society for the privilege of discussing the paper.

DR ELDAIF: Thank you very much. As it pertains to the short gastric question, just from our experience, it provides better mobilization, especially less tension, especially with the Toupet fundoplication. As for the leak rates, we had two patients that had postoperative leaks, and these were treated, again, surgically with no further complications. But also, as far as the postoperative esophagrams, they would allow us to evaluate those for the esophageal emptying, and, hence, give us more confidence in our repair.

DR DAVID TOM COOKE (Sacramento, CA): It was a great presentation. Your follow-up is approximately 36 months, and we all know a Heller myotomy for achalasia is a palliative operation and not a curative operation. That being said, what if you had a 50-year-old person with megaesophagus compared to an 80-year-old man or woman with megaesophagus? Would that influence your decision to do a Heller myotomy versus an esophagectomy?

And second is you define megaesophagus as anything greater than 6 cm. Is all megaesophagus the same? So if you see someone with a giant esophagus of 10 cm, or 8 or 9, would you be willing to do an esophagectomy in that patient or still attempt to do a myotomy?

DR ELDAIF: Thank you very much, Dr Cooke, for your questions. For your first question, a 50-year-old gentleman versus an 80-year-old gentleman, obviously with the results that we are showing here, it seems reasonable to offer either of them myotomy as the first choice, especially in light if they haven't had myotomies in the past, and even if they had one myotomy in the past, then repeat myotomies is actually not out of the question. So a myotomy, again, with the problems with the myotomy and an 80-year-old patient, I don't foresee any difference between a 50-year-old.

As for are all megaesophagus the same, this question was discussed in previous papers. There are the sigmoid variety versus just megaesophagus varieties, and most studies that have been done recently conclude that a myotomy, a laparoscopic myotomy in that respect, is a good choice because you can essentially reduce the floppiness of the esophagus into the stomach and this way provide a better surgical approach to that.

DR STEPHEN CASSIVI (Rochester, MN): I applaud you and your group for this research. I think it is important to understand that this type of procedure is doable. The idea of achalasia is they may not have motor activity in the body that we can give back to the patient, but we can at least let the back door open and let them drain their esophagus by gravity.

My question to you is, do we really burn any bridges by doing the myotomy? When you go back to do an esophagectomy, if that is all that is possible in the end, if they come back with persistent problems after an attempt at myotomy, has the prior myotomy impaired your ability to do the subsequent esophagectomy? I believe you had a few of these types of scenarios in your series.

DR ELDAIF: Thank you, Dr Cassivi. As for performing the esophagectomies, this was not mentioned during the presentation but it is in the paper. We performed most of them through a transthoracic approach, and this has allowed us to expose the esophagus and safely transect it and reconstruct it with no problems. So to answer the question, a myotomy does not really affect your exposure if you are doing a transthoracic approach. And then Dr Orringer and his group have commented that at times, a transhiatal approach could be affected by that, but we haven't done that in our institution.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Patti MG, Fisichella PM, Perretta S, et al. Impact of minimally invasive surgery on the treatment of esophageal achalasia: a decade of change J Am Coll Surg 2003;196:698-705.[Medline]
  2. Richards WO, Torquati A, Holzman, MD, et al. Heller esophagomyotomy versus Heller esophagomyotomy with Dor fundoplication. A prospective randomized double-blind clinical trial. Ann Surg 2004;240:405-415.[Medline]
  3. Bessell JR, Lally CJ, Schloithe A, Jamieson GG, Devitt PG, Watson DI. Laparoscopic cardioesophagomyotomy for achalasia. Long-term outcomes. ANZ J Surg 2006;76:558-562.[Medline]
  4. Abir F, Modlin I, Kidd M, Bell R. Surgical treatment of achalasia: current status and controversies Dig Surg 2004;21:165-176.[Medline]
  5. Deb S, Deschamps C, Allen MS, et al. Laparoscopic esophageal esophagomyotomy for achalasia: factors affecting functional results Ann Thorac Surg 2005;80:1191-1195.[Abstract/Free Full Text]
  6. Shiino Y, Houghton SG, Filipi CJ, Awad ZT, Tomonaga T, Marsh RE. Manometric and radiographic verification of esophageal body decompensation for patients with achalasia J Am Coll Surg 1999;189:158-163.[Medline]
  7. Miller DL, Allen MS, Trastek VF, Deschamps C, Pairolero PC. Esophageal resection for recurrent achalasia Ann Thorac Surg 1995;60:922-926.[Abstract/Free Full Text]
  8. Devaney EJ, Lannettoni, MD, Orringer MB, Marshall B. Esophagectomy for achalasia: patient selection and clinical experience Ann Thorac Surg 2001;72:854-858.[Abstract/Free Full Text]
  9. Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia. An 8-year experience with 168 patients. Ann Surg 1999;230:587-594.[Medline]
  10. Mineo TC, Pompeo E. Long-term outcome of Heller esophagomyotomy in achalasia sigmoid esophagus J Thorac Cardiovasc Surg 2004;128:402-407.[Abstract/Free Full Text]
  11. Sweet MP, Nipomnick I, Gasper WJ, et al. The outcome of laparoscopic Heller esophagomyotomy for achalasia is not influenced by the degree of esophageal dilatation J Gastrointest Surg 2008;12:159-165.[Medline]
  12. Hankins JR, Mclauglin JS. The association of carcinoma of the esophagus with achalasia J Thorac Cardiovasc Surg 1975;69:355-360.[Abstract]
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  14. Ellis JR FH, Crozier RE, Gibb SR. Reoperative achalasia surgery J Thorac Cardiovasc Surg 1986;92:859-865.[Abstract]
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  16. Okike N, Payne WS, Neufeld DM, Bernatz PE, Pairolero PC, Sanderson DR. Esophagomyotomy versus forceful dilation for achalasia of the esophagus results in 899 patients Ann Thorac Surg 1979;28:119-125.[Abstract/Free Full Text]




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