title: Esophagectomy for achalasia: patient selection and clinical experience.
abstract: BACKGROUND
  In 1989, we predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challenging, as the potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus.
  
  
  METHODS
  The hospital records of 93 patients undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively and the results of operation assessed using our prospectively established Esophageal Resection Database and follow-up information obtained through personal contact with the patients.
  
  
  RESULTS
  Patient age averaged 51 years. Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%). Ninety-four percent of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% cases. Intraoperative blood loss averaged 672 mL. Postoperative length of stay averaged 12.5 days. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis. Follow-up has averaged 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% have refractory postvagotomy dumping.
  
  
  CONCLUSIONS
  Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia. Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, large aortic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy.
authors.affiliation: Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109, USA.
authors.forename: E J
authors.initials: EJ
authors.lastname: Devaney
authors.forename: M D
authors.initials: MD
authors.lastname: Lannettoni
authors.forename: M B
authors.initials: MB
authors.lastname: Orringer
authors.forename: B
authors.initials: B
authors.lastname: Marshall
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004931:Esophageal Achalasia / Q000209:etiology / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods; D004944:Esophagoplasty; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome