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Results of Esophagectomy for Achalasia After Failed Intervention
Henning A Gaissert, Ning Lin, John C Wain, Cameron D Wright, Douglas J Mathisen
Massachusetts General Hospital, Boston, MA

Objective: End-stage achalasia as an indication for esophagectomy is sometimes defined by esophageal size and symptoms alone. We sought to evaluate esophagectomy when limited to patients after failed prior intervention.
Design: We conducted a retrospective analysis of patients with achalasia who underwent esophagectomy when myotomy after first intervention was not feasible.
Setting: University-affiliated tertiary care center
Patients: Among 86 patients operated for achalasia between 1960 and 2004, 14 (16.3 %) underwent esophagectomy for end-stage disease. Mean age was 55 years. Mean symptom duration was 17.1 (2-40) years. Prior interventions consisted of at least 1 myotomy in 10, pneumatic dilatation in 2, resection of the cardia in 1, and long-term (> 30 years) dilatation in 2 patients. Four patients required enteral tube alimentation.
Interventions: All patients underwent esophagectomy. Reconstruction consisted of gastric conduit in 9, short colon in 2, substernal colon in 1, and jejunal interposition in 2.
Main Outcome Measures: Operative mortality, independence of nutritional supplementation, long-term survival
Results: There was no mortality. Mean hospital stay was 14.8 days. Complications occurred in 43% (6/14). Follow-up was complete; mean follow-up was 10.8 years. After jejunal interposition, 1 patient required revision to esophagogastrostomy. Early postoperative dilatation was needed in 5 patients and late in 3. Eleven patients tolerated regular diet with some restrictions in 7, and 3 tolerated soft solids. No patient required tube feedings. Five patients have acid reflux or aspiration. Five patients have died (36%), 1 of advanced emphysema and aspiration.
Conclusions: Myotomy is the first surgical option in achalasia. In end-stage achalasia after failed intervention, esophageal resection and reconstruction with stomach, colon, or jejunum is safe and associated with acceptable long-term results.


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