How to cite this article: Barajas-Fregoso EM, Romero-Hernández T, Sánchez-Fernández PR, Fuentes-Orozco C, González-Ojeda A, Macías-Amezcua MD. Experience of the surgical management of the esophageal achalasia in a tertiary care hospital. Rev Med Inst Mex Seguro Soc. 2015 Jan-Feb;53(1):84-91.
CLINICAL AND SURGICAL PRACTICE
Received: March 15th 2013
Accepted: May 20th 2013
Elpidio Manuel Barajas-Fregoso,a Teodoro Romero-Hernández,a Patricio Rogelio Sánchez-Fernández,a Clotilde Fuentes-Orozco,b Alejandro González-Ojeda,b Michel Dassaejv Macías-Amezcuab
aServicio de Gastrocirugía, Hospital de Especialidades “Dr. Bernardo Sepúlveda”, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Distrito Federal, México
bUnidad de Investigación en Epidemiología Clínica, Unidad Médica de Alta Especialidad, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, México
Communication with: Michel Dassaejv Macías-Amezcua
Telephone: (312) 1571 112
Background: Achalasia is a primary esophageal motor disorder. The most common symptoms are: dysphagia, chest pain, reflux and weight loss. The esophageal manometry is the standard for diagnosis. The aim of this paper is to determine the effectiveness of the surgical management in patients with achalasia in a tertiary care hospital.
Methods: A case series consisting of achalasia patients, treated surgically between January and December of 2011. Clinical charts were reviewed to obtain data and registries of the type of surgical procedure, morbidity and mortality.
Results: Fourteen patients were identified, with an average age of 49.1 years. The most common symptoms were: dysphagia, vomiting, weight loss and pyrosis. Eight open approaches were performed and six by laparoscopy, with an average length of cardiomyotomy of 9.4 cm. Eleven patients received an antireflux procedure. The effectiveness of procedures performed was 85.7 %.
Conclusions: Surgical management offered at this tertiary care hospital does not differ from that reported in other case series, giving effectiveness and safety for patients with achalasia.
Keywords: Gastroesophageal reflux; Esophageal achalasia; Surgical procedures; Operative esophagoscopy
Achalasia is a primary motor disorder of the esophagus, with annual reported incidence in the United States from 0.5 to 1 per 100,000 population and prevalence of 8 cases per 100,000 inhabitants per year. There is no preference for gender, and age of onset is between 20 and 50 years.1-3
Although loss of esophageal myenteric neurons has been demonstrated as the underlying problem, it is still not clear why these neurons are attacked and destroyed preferentially by the immune system.4,5
Patients typically report progressive dysphagia from solids to liquids, which is exacerbated by stress and intake of cold fluids.1 Weight loss is variable and its magnitude is related to the severity of the disease.1,6
A chest radiograph may suggest the diagnosis upon finding the absence of gastric bubble and presence of dilated esophagus; contrast studies, particularly barium swallow, show a dilated esophagus without peristalsis, fluid level, and the characteristic image of the "bird beak", data suggesting the absence of relaxation of the inferior esophageal sphincter.4,5,7 The gold standard for its diagnosis is esophageal manometry, with sensitivity over 90%.4,7 The classic manometric findings are hypertensive lower esophageal sphincter, incomplete relaxation (or no relaxation) of the inferior esophageal sphincter, esophageal body aperistalsis, and high baseline inferior esophageal sphincter pressure.3-5,7
The goals of treatment are to remove the obstruction made by the lower esophageal sphincter, relieve dysphagia, and maintain the anti-reflux barrier.5 Current treatment options include drug therapy, application of botulinum toxin, endoscopic management through pneumatic dilation, and surgery.1,4,7
The aim of this paper is to report the results of surgical management of patients with achalasia at the Hospital de Especialidades “Dr. Bernardo Sepúlveda” of the Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social.
This is a series of cases. It includes patients with diagnosis of achalasia who underwent surgical treatment, performed by different unit surgeons in the Servicio de Gastrocirugía of the hospital mentioned, during the period January 1st to December 31st 2011. The study variables were age, gender, persistent symptoms at diagnosis, and duration. Regarding the diagnosis of the pathology, this was documented by manometry of esophageal body and inferior esophageal sphincter through resting pressure, percentage of relaxation, length of inferior esophageal sphincter, and motility of the esophageal body. The type of surgical approach, extent of myotomy, and supplementation with anti-reflux procedure were the technical points evaluated, as well as the presence of intraoperative and postoperative complications, morbidity, and mortality. Treatment response was assessed by the persistence of symptoms and postoperative dysphagia. For this the previously validated Likert scale of dysphagia severity was used:8-10
The data collected were analyzed using descriptive statistics: frequencies, percentages, means, standard deviations, and ranges, using the IBM program SPSS, version 17.0.
Fourteen patients were included, all without previous surgical treatment for achalasia, of which eight were women and six men, the average age was 49.1 ± 17 years (Table I).
|Table I Description of characteristics of patients evaluated (n = 14)|
|Sex||Age (years)||Time of development (months)||Manometric features||Previous dilations||Type of approach||Concomitant anti-reflux therapy||Bleeding (mL)||Length of myotomy (cm)||HS
|Static pressure mmHg||Relaxation
|70||56||37||48||0.4||1.2||1||OTA||None||30||10||10||Surgical wound infection|
|OTA = open transabdominal; L = laparoscopic; OTT = open transthoracic; LEI = length of the inferior esophageal sphincter; HS = hospital stay; GERD = gastroesophageal reflux disease|
Dysphagia was the predominant symptom present in all patients, followed by vomiting, weight loss, heartburn, and reflux. Aspiration was present in one patient. The time development of symptoms prior to surgical treatment was 40.6 ± 36.6 months.
Five patients underwent preoperative therapy, and endoscopic dilation was the technique used on the entire group. Also, five of the fourteen received concomitant therapy with proton-pump inhibitors (omeprazole).
Esophageal manometry reported an average basal inferior esophageal sphincter pressure of 37.4 ± 9.5 mmHg, and a relaxation of the lower esophageal sphincter of 52.9 ± 17.1%, with an average length of 2.9 ± 0.5 cm. In all cases esophageal body aperistalsis and adequate pharyngoesophageal coordination were observed.
Eight open approaches and six laparoscopic approaches were performed. Of the open surgeries, seven were abdominal and only one approach was transthoracic. Cardiomyotomy length was 9.4 ± 1.7 cm, proximal extension to the gastroesophageal junction was 6.9 ± 1.3 cm, and distal extension to the gastroesophageal junction was 2.6 ± 1.1 cm.
In 11 patients a concomitant anti-reflux procedure was performed; of these, seven underwent Dor fundoplication and four underwent Toupet fundoplication. Quantified intraoperative bleeding was 100 ± 88.1 mL. The number of days of hospital stay was 7.9 ± 2.4 days.
Among the complications from the surgical procedure, the study found: 3 mm esophageal perforation in one patient, which was repaired with primary closure; surgical wound infection and oral intolerance in another patient, and gastroesophageal reflux in two cases.
Morbidity secondary to the procedure occurred in three patients and there were no differences between the approaches taken, and no mortality. No reoperations were reported in the study group. Postoperative dysphagia was present in two patients; it was classified as grade I, so a therapeutic effectiveness of 85.71% was reported in the patients studied.
Achalasia is a primary motor esophageal disorder, whose main symptom is dysphagia.1-3
As for demographic characteristics, no gender preference was found in this study, and the patients had an average age of 49.1 ± 17.1 years, which represented a population mostly in productive ages. Previous studies showed a development time of 24-30 months;1,11 our study found the median time to progression at 40.6 ± 36.6 months, which was higher than that reported in the literature, plus the number of patients undergoing preoperative therapy was 35.7%; in this case the entire group underwent endoscopic dilatation, compared with previous studies that reported preoperative therapy in the range of 22 to 86%.11-13
The gold standard for achalasia diagnosis remains esophageal manometry, with which it is possible to identify hypertension and elevated basal pressure of the inferior esophageal sphincter, with absent or diminished relaxation.3-5,7 Based on this, in this study, diagnosis was made taking into account manometric criteria.
For the surgical treatment of this pathology Heller’s cardiomyotomy was described, which can be done by open and minimally invasive approach; the literature documents that the laparoscopic approach gives better visualization of the distal esophagus and stomach, as well as better results for the relief of dysphagia compared to open surgery (93% versus 85%), and less postoperative reflux (13% vs. 35%), respectively.1,4 In our series, 57.1% of the approaches were open, compared to 42.9% performed by laparoscopic procedure. The recommended length of myotomy in earlier studies is 6-8 cm proximal and 2-3 cm distal to the gastroesophageal junction;1 the length of myotomy in our center was 9.4 ± 1.7 cm.
The performance of a concomitant anti-reflux procedure during surgery in order to prevent postoperative gastroesophageal reflux has been standardized. In a study by Bloomston et al.,11 the percentage of anti-reflux surgery performed was only 26%; however, in other studies this figure increases up to 96%.14,15 78.6% of our patients received some type of concomitant anti-reflux therapy.
Postoperative dysphagia listed as grade I occurred in two patients, so the effectiveness of the procedures was 85.7%. This is consistent with previous studies in which response to dysphagia was 84-86% (Table II).13,15,16
|Table II Type of approach and pre- and post-surgical dysphagia behavior|
|Approach||Total||Pre-surgical dysphagia||Post-surgical dysphagia|
|* Procedure performed openly|
As for treatment by endoscopic dilatation, multiple studies have evaluated the clinical improvement of this condition (Table III). In total they included a total of 467 patients and quantified dysphagia subsequent to the procedure in order to report clinical improvement. These studies demonstrated an upward trend of dysphagia in relation to time: in the first month average reported clinical improvement was 84.4% (range 56-90%), at six months 70% (range 61-79%), and at one year 68.2% (range 54-90%). There was an average of 2.25 (range 1-4) perforations per study as the most frequent and serious complication, and a total of 127 reoperations of which 106 consisted of a second dilation and 21 Heller’s myotomies. This shows low effectiveness of treatment as a single procedure to treat achalasia.17-23 In our study 35.7% of patients undergoing surgical procedure had a history of having previously received endoscopic dilation; these patients eventually required surgery for definitive treatment.
|Table III International experience in addressing esophageal achalasia with endoscopic balloon dilation|
|< 1 month||90%||97%||56%||–||83%||–||96%|
|* Value reported using various quantifying tests of dysphagia, after first balloon dilatation|
There are several surgical approaches for treatment of the disease in question, including open transabdominal and transthoracic procedures, which have a marked difference in clinical improvement and complications. For transabdominal, multiple studies have shown clinical improvement of 89.7%, and major complications reported have been GERD and tearing of the esophageal mucosa, with an average hospital stay of 7.5 days (range 5.4 to 8) and an average reoperation rate of 2 (Table IV).14,24-28 In the case of our patients, one (out of seven with open transabdominal approach) presented post-surgical dysphagia grade I. In contrast to the transthoracic approach, studies report a clinical improvement of 82.5%, with a higher rate of complications, hospital stay, and reoperations (Table V).29-34 In our one case of transthoracic approach the patient did not present dysphagia, but showed postoperative reflux.
|Table IV International experience in transabdominal approach to esophageal achalasia|
* Value reported using various quantifying tests of dysphagia, at 12 months from surgical procedure
GERD = gastroesophageal reflux disease;SW = surgical wound;HS = hospital stay
|Table V International experience on transthoracic approach to esophageal achalasia|
*Value reported using different quantifying tests of dysphagia, at 12 months from surgical procedure
HS = hospital stay;GERD = gastroesophageal reflux disease;SW = surgical wound
Most of the authors prefer the laparoscopic approach because it offers an excellent view of the distal esophagus and stomach, which also allows the anti-reflux procedure, which documents better results in the relief of dysphagia with the laparoscopic approach (93 % versus 85%) as well as lower hospital stay (48 hours versus 72 hours) and less postoperative reflux (13% versus 35%).1,4,11-13,15,16,35,36
Several international studies have evaluated the functional results of laparoscopic surgery for achalasia (Table VI). These studies have a grand total of 825 patients, in which the approach was Heller’s myotomy and Dor or Toupet fundoplication. The value used in all studies to report clinical improvement was based on the quantification of dysphagia, of which 81% (range 63-89%) was obtained as the average value of improvement with such treatment. A total of 70 surgical complications were presented, which include a total of 54 esophageal perforations, eight chemical burns from aspiration, 15 pneumothorax, two hemorrhages, and one liver laceration. Postoperative complications included a total of 11 pneumonias, presence of esophageal diverticula in three patients, and only two surgical wound infections, totaling 16 complications. Also, a total of 32 reinterventions were reported.11-13,15,16,35,36 Previous studies show a similarity with the results of the laparoscopic approach to this disease in our center.
|Table VI International experience in laparoscopic approach to esophageal achalasia|
|Reported improvement *||63%||86%||84%||84%||80%||89%||85%|
|Aspiration into lungs||–||–||–||–||1||2||6||20||–||1||1.5|
|Post-surgical complications (%)|
* Value reported using different quantifying tests of dysphagia, at 12 months from surgical procedure
HS = hospital stay;GERD = gastroesophageal reflux disease;SW = surgical wound
Achalasia is and will remain a complex pathology that, beyond dysphagia as the cardinal symptom, presents other clinical manifestations that together cause a serious and progressive state of health deterioration for the patient, so diagnosis and proper treatment done by skilled surgeons is essential for success in the treatment of this pathology. It is noteworthy that there are many non-surgical treatment options; however, over time and as disease symptoms are aggravated, it will be essential to do cardiomyotomy with minimally invasive surgery as an approach due to the advantages it offers.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.