Asian Journal of Case Reports in Surgery

Achalasia as Unusual Indication of Esophagectomy: A Case Report

Julio Gonzalez Garcia *

Department of General Surgery UMAE, Hospital de Especialidades, CMNO Av. Belisario Domínguez No. 1000 Col. Independencia CP 44340, Guadalajara, Jalisco, Mexico.

Dulce Carolina Lopez Graciano

Department of Cirugía General UMAE, Hospital de Especialidades, CMNO Av. Belisario Domínguez No. 1000 Col. Independencia CP 44340, Guadalajara, Jalisco, Mexico.

Paulina Rodriguez Flores

Department of Cirugía General UMAE, Hospital de Especialidades, CMNO Av. Belisario Domínguez No. 1000 Col. Independencia CP 44340, Guadalajara, Jalisco, Mexico.

Gustavo Delgado Muñoz

Department of Cirugía General UMAE, Hospital de Especialidades, CMNO Av. Belisario Domínguez No. 1000 Col. Independencia CP 44340, Guadalajara, Jalisco, Mexico.

*Author to whom correspondence should be addressed.

---

Abstract

Achalasia is a rare desease. Treatment options in delayed stages like sigmoid esophagus are heller myotomy and esophagectomy.  This case report aims to show the anatomy variations, strength, and outcomes of esophagectomy with and hybrid technique.

Presentation of Case: A 69-year-old man presented with a long history of dysphagia, regurgitation, and smoking history. An esophagectomy was done. A common complication presented (fistula) and other not so common; pyloric obstruction. Then the patient improved with conservative management.

Discussion: the purpose of this review is to comparate the different treatment options for end-stage achalasia, one of them is esophagectomy which involves a certain degree of difficulty compared to other indications for esophagectomy. Esophagectomy in patients with achalasia seems a safe procedure. Others treatment options used for end-stage achalasia or for failure from other treatment options for achalasia like Heller's myotomy, pneumotic dilatations or POEM.

Conclusion: Treatment options for end-stage achalasia range from conventional treatment (endoscopic, heller myotomy) to esophageal resection, with very specific indications. Morphological alterations in end-stage achalasia are a surgical challenge. Knowledge of postoperative complications and their treatment has important implications for the right management.

Keywords: Achalasia, esophagectomy, minimally invasive approach, three-hole esophagectomy, left aberrant hepatic artery

---

---

---

References

Epidemiology and demographics of achalasia - PubMed [Internet]. [cited 2023 Mar 6]. Available from: https://pubmed.ncbi.nlm.nih.gov/11319059/

Townsend CM, Beauchamp RD, Evers BM, Mattox KL, Sabiston DC. Sabiston textbook of surgery : the biological basis of modern surgical practice. 21°. 2021. 1049–106 p.

Annese V, Basciani M, Perri F, Lombardi G, Frusciante V, Simone P, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia. Gastroenterology [Internet]. 1996 [cited 2023 Mar 6];111(6):1418 –24. Available:https://pubmed.ncbi.nlm.nih.gov/8942719/

Leyden JE, Moss AC, Macmathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Vol. 2014, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2014.

Jara FM, Toledo-Pereyra LH, Lewis JW, Magilligan; DJ. Long-term Results of Esophagomyotomy for Achalasia of Esophagus [Internet]. Arch Surg. 1979; 114. Available:http://archsurg.jamanetwork.com/

Ortiz A, De Haro LFM, Parrilla P, Lage A, Perez D, Munitiz V, et al. Very long-term objective evaluation of Heller myotomy plus posterior partial fundoplication in patients with achalasia of the cardia. Ann Surg. 2008;247(2):258–64.

Campos GM, Vittinghoff E, Rabl C, Takata M, Gadenstätter M, Lin F, et al. Endoscopic and surgical treatments for achalasia: A systematic review and meta-analysis. Ann Surg. 2009;249(1):45–57.

Lin J, Iannettoni MD. Transhiatal esophagectomy. Vol. 85, Surgical Clinics of North America. 2005. p. 593–610.

Duranceau A, Liberman M, Martin J, Ferraro P. End-stage achalasia. Vol. 25, Diseases of the Esophagus. 2012. p. 319–30.

Descriptive Rules for Achalasia of the Esophagus, June 2012: 4th Edition. Esophagus [Internet]. 2017 Oct 1 [cited 2023 Mar 7];14(4):275–89. Available:https://pubmed.ncbi.nlm.nih.gov/28983228/

Roll GR, Rabl C, Ciovica R, Peeva S, Campos GM. A controversy that has been tough to swallow: is the treatment of achalasia now digested? J Gastrointest Surg [Internet]. 2010 Feb [cited 2023 Mar 7];14 Suppl 1(Suppl 1). Available from: https://pubmed.ncbi.nlm.nih.gov/19760373/

Pinotti HW, Cecconello I, da Rocha JM, Zilberstein B. Resection for achalasia of the esophagus. Hepatogastroenterology [Internet]. 1991 Dec;38(6):470—473. Available:http://europepmc.org/abstract/MED/1778572.

Patti MG, Feo C V., Diener U, Tamburini A, Arcerito M, Safadi B, et al. Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated. Surg Endosc [Internet]. 1999 Sep [cited 2023 Mar 7];13(9):843–7. Available from: https://pubmed.ncbi.nlm.nih.gov/10449836/

Ruffato A, Mattioli S, Lugaresi ML, D’Ovidio F, Antonacci F, Di Simone MP. Long-term results after Heller-Dor operation for oesophageal achalasia. Eur J Cardiothorac Surg [Internet]. 2006 Jun [cited 2023 Mar 7];29(6):914–9.

Available:https://pubmed.ncbi.nlm.nih.gov/16675239/

Hu JW, et al. “Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: Long-term outcomes from a prospective, single-center study,” Surgical Endoscopy. 2014; 29(9):2841–2850. Available:https://doi.org/10.1007/s00464-014-4013-9.

Orringer MB, Stirling MC. Esophageal resection for achalasia: indications and results. Ann Thorac Surg [Internet]. 1989 [cited 2023 Mar 7];47(3):340–5. Available:https://pubmed.ncbi.nlm.nih.gov/2649031/

Peters JH, Kauer WKH, Crookes PF, Ireland AP, Bremner CG, Demeester TR. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg [Internet]. 1995 [cited 2023 Mar 7];130(6):632–7.

Available:https://pubmed.ncbi.nlm.nih.gov/7763172/

Harrington C, Molena D. “Minimally invasive Ivor Lewis esophagectomy in 10 steps. JTCVS Techniques. 2021;10:489–494. Available:https://doi.org/10.1016/j.xjtc.2021.04.038.

Maki H, Satodate H, Satou S, Nakajima K, Nagao A, Watanabe K, et al. Clinical evaluation of the aberrant left hepatic artery arising from the left gastric artery in esophagectomy. Surgical and Radiologic Anatomy. 2018 Jul 1;40(7):749–56.

Oki E, Sakaguchi Y, Hiroshige S, Kusumoto T, Kakeji Y, Maehara Y. Preservation of an aberrant hepatic artery arising from the left gastric artery during laparoscopic gastrectomy for gastric cancer. J Am Coll Surg. 2011 May;212(5).

Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical Outcomes After Esophagectomy in Patients with Achalasia: a NSQIP Matched Analysis With Non-Achalasia Esophagectomy Patients. Journal of Gastrointestinal Surgery. 2021 Oct 1;25(10):2455–62.

Famiglietti A, Lazar JF, Henderson H, Hamm M, Malouf S, Margolis M, et al. Management of anastomotic leaks after esophagectomy and gastric pull-up. J Thorac Dis [Internet]. 2020 Mar 1 [cited 2023 Mar 7];12(3):1022–30.

Available:https://pubmed.ncbi.nlm.nih.gov/32274171/

Fabbi M, Hagens ERC, Van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus [Internet]. 2021 Jan 1 [cited 2023 Mar 7];34(1). Available:https://pubmed.ncbi.nlm.nih.gov/32476017/

Brown AM, Pucci MJ, Berger AC, Tatarian T, Evans NR, Rosato EL, et al. A standardized comparison of peri-operative complications after minimally invasive esophagectomy: Ivor Lewis versus McKeown. Surg Endosc [Internet]. 2018 Jan 1 [cited 2023 Mar 7];32(1):204–11. Available:https://link.springer.com/article/10.1007/s00464-017-5660-4.

Fumagalli U, Baiocchi GL, Celotti A, Parise P, Cossu A, Bonavina L, et al. Incidence and treatment of mediastinal leakage after esophagectomy: Insights from the multicenter study on mediastinal leaks. World J Gastroenterol [Internet]. 2019 Jan 1 [cited 2023 Mar 7];25(3):356. Available: /pmc/articles/PMC6343094/

Kassis ES, Kosinski AS, Ross P, Koppes KE, Donahue JM, Daniel VC. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg [Internet]. 2013 Dec [cited 2023 Mar 7];96(6):1919–26. Available:https://pubmed.ncbi.nlm.nih.gov/24075499/

Markar SR, Arya S, Karthikesalingam A, Hanna GB. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol [Internet]. 2013 [cited 2023 Mar 7];20(13):4274–81. Available:https://pubmed.ncbi.nlm.nih.gov/23943033/

Nobel T, Tan KS, Barbetta A, Adusumilli, P, Bains M, Bott M, Jones D, Molena D. Does pyloric drainage have a role in the era of minimally invasive esophagectomy?. Surgical endoscopy. 2019;33(10):3218–3227. Available:https://doi.org/10.1007/s00464-018-06607-8.