Adult Chest Surgery

Chapter 28. Esophagectomy 

 

The need for esophageal replacement in patients with benign esophageal dysmotility is relatively uncommon. Esophagectomy carries a significant morbidity and mortality risk and should be considered very carefully before it is used in patients with "benign" disease. Nor do any of the methods of reconstruction restore the patient's esophagus to normal physiology and function. Even the best of outcomes usually are associated with some abnormality in swallowing, a potential for regurgitation and aspiration, and some sequelae secondary to division of both vagal nerves. There are no hard-and-fast criteria defining the indications for esophagectomy in these patients. The disabling symptoms that prompt a decision for resection and replacement are most commonly those associated with obstruction (e.g., dysphagia, regurgitation, and aspiration), unmanageable pain (e.g., odynophagia owing to esophageal spasm), and/or disabling gastroesophageal reflux. Furthermore, almost all these patients have undergone one or more previous operations to manage their original motor abnormality. Ultimately, the surgeon must conclude that there is little or no prospect of a satisfactory outcome with medical or surgical management other than resection and reconstruction. The assessment of operative risk and likely outcome is frequently complex and difficult and is commonly best made after a frank and realistic review with the patient.

INDICATIONS FOR RESECTION AND REPLACEMENT

Indications for esophagectomy are subdivided by pathology into primary and secondary motor disorders. The primary motor disorders include achalasia, diffuse esophageal spasm, and rare, ill-defined derangements of esophageal dysmotility. Achalasia is by far the most common indication for resection and reconstruction in the primary group. Secondary motor disorders that sometimes require resection and replacement include esophageal scleroderma and rare instances of severe and disabling loss of effective peristalsis as a consequence of gastroesophageal reflux disease (GERD). Chagas' disease, a parasitic infection that is endemic in South America, resembles achalasia in many ways but results in significantly different alterations of the esophageal wall.

PRIMARY MOTOR DISORDERS

Achalasia

Achalasia is inevitably a progressive and incurable disease. All therapy is at best palliative, and the results of surgical treatment continue to deteriorate with the passage of time. This observation is supported in a number of publications reporting long-term follow-up in series of patients managed by a short esophagomyotomy with or without the addition of an antireflux reconstruction.1–5

LONG-TERM RESULTS OF ESOPHAGOMYOTOMY

Ellis and colleagues reported long-term results in a large number of patients managed by a transthoracic short esophagomyotomy without antireflux reconstruction.6 At the end of 1 year, 91% of patients registered good to excellent results. However, when 57 of these patients were evaluated over the long term (median 13.6 years), only 67% still registered good to excellent outcomes. Ten percent were classified as poor. These failures largely presented with disabling dysphagia, which Ellis and colleagues attributed to the natural progression of achalasia over time.

Malthaner and colleagues reported on 22 patients with newly diagnosed achalasia managed at Toronto General Hospital by a transthoracic esophagomyotomy combined with a Belsey Mark IV antireflux reconstruction.7 All 22 patients were followed for longer than 10 years (10–23 years). At the end of 1 year, all 22 patients were improved, and 21 of the 22 (96%) registered good to excellent categories. The good to excellent results diminished to 69% at the end of 10 years and to 67% after 20 years. The deterioration in results almost exclusively was a result of the development and progression of GERD with gross endoscopic esophagitis and stricture. Three of the twenty-two patients ultimately were managed by esophagectomy and gastric replacement (cervical anastomosis) was performed 7, 19, and 23 years after the initial esophagomyotomy. A fourth patient was palliated successfully with antrectomy, vagotomy, and Roux-en-Y diversion at 23 years.

Ruffato and colleagues, from Bologna, reported the long-term results of extended esophagomyotomy reinforced with a Dor fundoplication.8 Of the 173 patients, 68 were followed for more than 15 years. The authors reported subsequent esophageal cancer in four patients performed 27, 46, 96, and 144 months after initial myotomy. Poor results were managed by additional surgery in 22 of these patients, and in 15 of these 22, failed outcome was due to the development of disabling GERD. Management included esophagectomy in two, antrectomy and Roux-en-Y diversion in two, and a second antireflux reconstruction in two. The remaining 7 of these 22 failures were patients with a grossly dilated sigmoid esophagus. Six of these seven patients underwent esophagectomy. It was noted that 26 patients had a grossly dilated sigmoid esophagus at initial presentation. The authors proposed that primary surgical treatment with esophagectomy may be a reasonable consideration when patients present with advanced degrees of esophageal dilatation and tortuosity.

Gaissert and colleagues, from the Massachusetts General Hospital, reviewed 64 consecutive patients with achalasia managed by esophagomyotomy (with and without fundoplication).9 Thirty-one of these patients were followed for more than 10 years. The authors recorded good to excellent short-term results in 91% of patients, but this category deteriorated to 63% at and beyond 10 years. Dysphagia persisting after operation was a harbinger of late failure. Four of the thirty-one long-term patients developed a peptic stricture, and two of these thirty-one ultimately were managed by esophagectomy.

Glatz and colleagues, in Louisville, Kentucky, reported their experience with eight patients managed by Ivor Lewis esophagectomy after prior unsuccessful esophagomyotomy.10 Five of these eight patients had advanced esophageal dilatation with a sigmoid configuration. The mean time from esophagomyotomy to esophagectomy was 12.5 years (range 2–18 years, median 14 years). At final pathology, two of the patients were found to have an occult squamous carcinoma (invasive in one and in situ in the other, both located in the middle third of the esophagus).

INDICATIONS FOR ESOPHAGECTOMY IN ACHALASIA

It is difficult to identify precise indications or categories of failure that would prompt the decision for esophagectomy and reconstruction in patients with achalasia. The earliest reports in the medical literature are found in the early 1980s.11,12 Since that time, there has been an increasing number of reports documenting experience from several well-known surgical centers with a significant interest in the management of benign motor disorders of the esophagus.1,2,13–17

Most patients for whom esophagectomy is indicated have undergone one or more operations, beginning with esophagomyotomy performed with or without an antireflux reconstruction. The reasons for subsequent failure leading to esophagectomy are disabling obstruction with dysphagia and regurgitation, disabling GERD exacerbated by the concomitant achalasia, or recognition of malignancy in the squamous epithelium of the esophagus.

DYSPHAGIA

Dysphagia is the most common indication prompting a decision for esophagectomy. The origin of dysphagia may prove difficult to determine even after extensive evaluation with contrast examinations, endoscopy, manometry, pH studies, or observations made at surgical exploration.

The disabling symptoms frequently are attributed to the late complications of GERD. These include intractable peptic ulceration, peptic stricture, and Barrett's columnar replacement with Barrett ulcer.2–6,10–14 Malthaner and colleagues found that the incidence of severe GERD increased with the passage of time after esophagomyotomy.7 Severe manifestations of GERD were identified in 15% of patients followed beyond 15 years. Esophagectomy in these patients is done most frequently 10 or more years after the original surgery.3–5

Disabling dysphagia may persist or progress in patients, with the most advanced changes occurring in a grossly dilated, redundant "sigmoid" megaesophagus. In such patients, the distended distal esophagus may lie in the posterior mediastinum at a level well below the diaphragmatic hiatus. This large distal reservoir is rarely, if ever, empty of food and fluid. Although such redundancy may be diminished with the operation of open transthoracic myotomy (some of the redundant distal esophagus can be positioned below the hiatus), such correction is difficult, if not impossible, with the laparoscopic myotomy that prevails today. Orringer and colleagues were the first to suggest that when such advanced cases are seen in patients at suitable risk, esophagectomy may be the preferred primary operation.12 A similar recommendation was made by Ruffato and colleagues in 2006.8

Ellis and colleagues in 198613 and again in 199218 attributed poor results to the natural progression of this incurable disease with the passage of time. The 1992 paper by Ellis and colleagues18 reported 10- and 20-year follow-up results in a significant number of patients. Follow-up, however, did not include a critical evaluation of the role of GERD.

INTRACTABLE REFLUX

In addition to obstruction, GERD may create intractable symptoms of painful retrosternal distress, acid regurgitation, and aspiration. Esophagectomy may be advised if some form of local antireflux operation is considered likely to fail. A safer alternative to resection in such patients may be an antrectomy, vagotomy, and diverting Roux-en-Y jejunal gastroenterostomy. Favorable results with this operation have been reported by Fekete and colleagues,11 Ellis and colleagues,13 Gayet and Fekete,2 and Miller and colleagues.15

CARCINOMA OF THE ESOPHAGUS

Squamous cell carcinoma is a known complication of long-standing achalasia. The cancer usually develops in the middle third of the esophagus and frequently is reported as an asymptomatic and unsuspected incidental finding at pathology. When such malignancies do become symptomatic, they are almost always advanced and incurable. Obstruction resulting in dysphagia owing to malignancy develops late in the grossly dilated esophagus of achalasia. Furthermore, the mucosal changes of early malignancy are difficult or impossible to identify at endoscopy. Early abnormalities are obscured by retained food and secretions, the presence of leukoplakia, and inflammatory changes of retention esophagitis, all of which are seen in long-standing achalasia. Skinner and Belsey provide a concise but comprehensive review of malignancy secondary to achalasia. In Belsey's personal series, the incidence of squamous cell cancer was 8% (12 of 158 consecutive cases followed for more than 6 years). All 12 cases were at middle third level, and only one patient survived beyond 5 years.

TYPE OF ESOPHAGECTOMY USED FOR ACHALASIA

A detailed review of the options for esophagectomy and reconstruction can be found in Chap. 21. Part 2 also contains individual chapters that describe the many different approaches to esophagectomy that have evolved over the years.

When the dominant reason for esophagectomy is dysphagia with obstruction and regurgitation, a total thoracic esophagectomy is advised, with the esophagogastric anastomosis in the neck or high in the posterior mediastinum (high Ivor Lewis procedure). All the various techniques of total thoracic esophagectomy have been used and include the transhiatal esophagectomy popularized by Orringer and Stirling.1 A low intrathoracic anastomosis is highly susceptible to damage by reflux, which is aggravated by the remaining aperistaltic thoracic esophagus.

If operation is indicated for squamous cell cancer, which almost invariably develops in the middle third of the thoracic esophagus, a total thoracic esophagectomy is the obvious choice.19 In patients suffering primarily from the disabling symptoms of GERD, an attractive and less morbid alternative to total thoracic esophagectomy is antrectomy, vagotomy, and bile diversion with Roux-en-Y gastrojejunostomy. This operation has been popularized and is increasingly promoted by both Fekete and colleagues in Paris11,20 and Ellis and colleagues in Boston.13,18

Diffuse Esophageal Spasm

Diffuse esophageal spasm is a relatively rare condition of obscure etiology that is difficult to treat medically or surgically with predictably good outcomes. The generally accepted surgical operation consists of a long esophagomyotomy extending from the esophagogastric junction below to the lower border of the aortic arch (or higher) above. The condition is very well reviewed in a report by Ellis published in 1998.21

Odynophagia is the most disabling symptom and is the main indication for esophagectomy. When pain becomes intractable (unbearable to the patient), despite the best available medication and failure of long esophagomyotomy, esophagectomy may be the "court of last resort." Orringer and Orringer reported on 22 patients with esophageal neuromotor dysfunction who were managed by esophagectomy.12 Eight of these twenty-two patients had primary esophageal spasm. Young and colleagues reported the Mayo Clinic experience with esophagectomy for benign disease between the years 1956 and 1997.16 In a total of 255 patients, they had 10 who were resected for diffuse esophageal spasm. Here again, the resection should remove all malfunctioning thoracic esophagus, which will require a high intrathoracic or cervical anastomosis.

SECONDARY MOTOR DISORDERS

Scleroderma

Scleroderma is a collagen-vascular disease that frequently results in loss of contractile function of smooth muscle in the gastrointestinal tract. The esophagus is a common site of gastrointestinal involvement, and the loss of smooth muscle contractility results in progressive, even complete loss of esophageal peristalsis. The stomach is often afflicted, and the resulting delayed gastric emptying further promotes reflux. Additionally, the lower esophageal sphincter pressure is progressively ablated.

Understandably, this pathology predisposes to free gastroesophageal reflux with severe complications, including peptic stricture and aspiration. Antireflux surgery may decrease the magnitude of GERD, but there is a reported high incidence of subsequent failure owing to continued disabling reflux and dysphagia.22–25 The high incidence of postoperative reflux and dysphagia reported in these four publications is summarized in detail in a recent paper by Kent and colleagues.26

Esophagectomy has been reported in patients with failed outcomes after antireflux repairs.12,16,27,28 If esophagectomy is selected in the management of patients with scleroderma, it seems reasonable to recommend resection of most of the thoracic esophagus and an esophagogastric anastomosis high in the thorax or in the neck. A limited resection and low anastomosis will predispose to an unacceptable incidence of ongoing severe GERD.

An alternative to esophagectomy in these difficult cases is reported by Fekete and colleagues from Paris, namely, total duodenal diversion by antrectomy and Roux-en-Y gastrojejunostomy.29 More recently, Kent and colleagues, in Pittsburgh, have reported favorable results using laparoscopic Roux-en-Y gastric bypass in eight patients.26 Compared with esophagectomy, these alternative operations carry a significantly reduced operative morbidity and mortality.

Chagas' Disease

Chagas' disease is a parasitic infection that is endemic to rural Brazil. More than 8 million persons are infected with the trypanosome, Trypanosoma cruzi, and 5% of this infected population develops motor changes in the esophagus. Esophageal involvement ultimately results in dilatation leading to megaesophagus with symptoms of dysphagia and regurgitation. The clinical presentation and radiologic appearance certainly resemble achalasia. The final pathology, however, is different. In earlier stages of Chagas' disease, the dilatation is associated with smooth muscle hypertrophy, as in achalasia. With progression, however, the dilatation becomes extreme, and the muscular wall of the esophagus becomes thin and atrophied. At this stage, the blood supply to the esophagus is reduced, unlike the expanded circulation encountered in achalasia. This advanced stage of the disease is labeled dolichomegaesophagus. Esophagectomy at this stage is not beset with the same risk of surgical bleeding seen in patients with classic achalasia. Esophagectomy and replacement frequently are done in these advanced-stage patients.

A report by Pinotti and colleagues from Sao Paulo, Brazil, provides a detailed outline of the condition and details of management in 840 patients, 722 with the less advanced stage of megaesophagus and 118 with dolichomegaesophagus. Pinotti's publication includes a pertinent bibliography.14

EDITOR'S COMMENT

Esphagectomy for progressive benign motor disorders of the esophagus may be more challenging than for cancer, partly because of scarring from previous surgery and abnormalities of the esophagus due to chronic disease. One should anticipate the possibility of large arterial branches from the aorta supplying the mid and lower esophagus.

–RB

REFERENCES

1. Orringer MB, Stirling MC: Esophageal resection for achalasia: Indications and results. Ann Thorac Surg 47:340–5, 1989.[PubMed: 2649031]

2. Gayet B, Fekete F: Surgical management of failed esophagomyotomy (Heller's operation). Hepatogastroenterology 38:488–92, 1991.[PubMed: 1778575]

3. Ellis H: Failure after esophagomyotomy for esophageal motor disorders: Causes, prevention, and management. Chest Surg Clin North Am 7:476–88, 1997. 

4. Bonavina L, Nosadini A, Bardini R, et al: Primary treatment of esophageal achalasia: Long-term results of myotomy and Dor fundoplication. Arch Surg 127:222–6; discussion 227, 1992. 

5. Chen L, Chughtai T, Sideris L, et al: Long-term effects of myotomy and partial fundoplication for esophageal achalasia. Dis Esophagus 15:171–9, 2002.[PubMed: 12220428]

6. Ellis FH Jr, Crozier RE, Watkins E Jr: Operation for esophageal achalasia: Results of esophagomyotomy without an antireflux operation. J Thorac Cardiovasc Surg 88:344–51, 1984.[PubMed: 6471885]

7. Malthaner RA, Tood TR, Miller L, Pearson FG: Long-term results in surgically managed esophageal achalasia. Ann Thorac Surg 58:1343–6; discussion 1346–7, 1994. 

8. Ruffato A, Mattioli S, Lugaresi ML, et al: Long-term results after Heller-Dor operation for oesophageal achalasia. Eur J Cardiothorac Surg 29:914–9, 2006.[PubMed: 16675239]

9. Gaissert HA, Lin N, Wain JC, et al: Transthoracic Heller myotomy for esophageal achalasia: Analysis of long-term results. Ann Thorac Surg 81:2044–9, 2006.[PubMed: 16731127]

10. Glatz SM, Richardson JD: Esophagectomy for end stage achalasia. J Gastrointest Surg 11:1134–7, 2007.[PubMed: 17623258]

11. Fekete F, Breil P, Tossen JC: Reoperation after Heller's operation for achalasia and other motility disorders of the esophagus: A study of eighty-one reoperations. Int Surg 67:103–10, 1982.[PubMed: 7118464]

12. Orringer MB, Orringer JS: Esophagectomy: Definitive treatment for esophageal neuromotor dysfunction. Ann Thorac Surg 34:237–48, 1982.[PubMed: 7114944]

13. Ellis FH Jr, Crozier RE, Gibb SP: Reoperative achalasia surgery. J Thorac Cardiovasc Surg 92:859–65, 1986.[PubMed: 3773541]

14. Pinotti HW, Cecconello I, da Rocha JM, Zilberstein B: Resection for achalasia of the esophagus. Hepatogastroenterology 38:470–3, 1991.[PubMed: 1778572]

15. Miller DL, Allen MS, Trastek VF, et al: Esophageal resection for recurrent achalasia. Ann Thorac Surg 60:922–5; discussion 925–6, 1995. 

16. Young MM, Deschamps C, Trastek VF, et al: Esophageal reconstruction for benign disease: Early morbidity, mortality, and functional results. Ann Thorac Surg 70:1651–5, 2000.[PubMed: 11093504]

17. Devaney EJ, Lannettoni MD, Orringer MB, Marshall B: Esophagectomy for achalasia: Patient selection and clinical experience. Ann Thorac Surg 72:854–8, 2001.[PubMed: 11565670]

18. Ellis FH Jr, Watkins E Jr, Gibb SP, Heatley GJ: Ten- to 20-year clinical results after short esophagomyotomy without an antireflux procedure (modified Heller operation) for esophageal achalasia. Eur J Cardiothorac Surg6:86–9; discussion 90, 1992. 

19. Little AG, Soriano A, Ferguson MK, et al: Surgical treatment of achalasia: Results with esophagomyotomy and Belsey repair. Ann Thorac Surg 45:489–94, 1988.[PubMed: 3365039]

20. Perniceni T, Gayet B, Fekete F: Total duodenal diversion in the treatment of complicated peptic oesophagitis. Br J Surg 75:1108–11, 1988.[PubMed: 3208045]

21. Ellis FH Jr: Long esophagomyotomy for diffuse esophageal spasm and related disorders: An historical overview. Dis Esophagus 11:210–4, 1998.[PubMed: 10071800]

22. Henderson RD, Pearson FG: Surgical management of esophageal scleroderma. J Thorac Cardiovasc Surg 66:686–92, 1973.[PubMed: 4746347]

23. Orringer MB, Orringer JS, Dabich L, Zarafonetis CJ: Combined Collis gastroplasty-fundoplication operations for scleroderma reflux esophagitis. Surgery 90:624–30, 1981.[PubMed: 7281001]

24. Mansour KA, Malone CE: Surgery for scleroderma of the esophagus: A 12-year experience. Ann Thorac Surg 46:513–4, 1988.[PubMed: 3190323]

25. Poirier NC, Taillefer R, Topart P, Duranceau A: Antireflux operations in patients with scleroderma. Ann Thorac Surg 58:66–72; discussion 72–3, 1994. 

26. Kent MS, Luketich JD, Irshad K, et al: Comparison of surgical approaches to recalcitrant gastroesophageal reflux disease in the patient with scleroderma. Ann Thorac Surg 84:1710–5; discussion 1715–6, 2007. 

27. Fell SC, Chang P, Brenner S: Esophagectomy for scleroderma stricture of esophagus. NY State J Med. 80:942–6, 1980.[PubMed: 6931298]

28. Mansour KA: Surgery for scleroderma of the esophagus: A 12-year experience (1988). Updated in 1995. Ann Thorac Surg 60:227, 1995.[PubMed: 7598607]

29. Fekete F, Kabbej M, Sauvanet A: Total duodenal diversion in the treatment of complex peptic esophagitis. Chirurgie 121:326–8; discussion 328–9, 1996. 



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