Title : Surgical treatment of advanced esophageal achalasia
Abstract:
Endoscopic and/or laparoscopic myotomy has shown positive results in non-advanced esophageal achalasia due to the development of this surgical technique currently. For the most advanced stages of the disease, esophagectomy seems to be the most indicated procedure due to the involvement of the entire esophagus, which prompted PINOTTI (PINOTTI,1976,1977) to disseminate the transmediastinal esophagectomy technique in the 1970s with the advantage of avoiding thoracotomy. Nevertheless, several series demonstrated that this technique was not exempt from complications, one of which could lead to massive hemopneumothorax with potential fatal evolution due to injury to the tracheobronchial tree and vessels due to periesophagitis that may be present with consequent adherence of the esophagus to these noble organs of the mediastinum. Because of this, AQUINO (AQUINO, 1996) in the 1990s introduced the esophageal mucosectomy (EM) technique with preservation of the esophageal muscle tunic at the level of the mediastinum as well as the transposition of the stomach to the cervical region inside this tunic for the reconstruction of the digestive transit. The greatest advantage of this procedure is to avoid transgression of the mediastinum and consequently the potential pleuromediastinal complications. To date, 136 patients with advanced esophageal achalasia have undergone this procedure, having as early postoperative complications (up to 30 PO days): dehiscence of the cervical esophagogastric anastomosis -19p (13.9%), with good outcome, pleural effusion- 13p (9.3%), with good evolution; pulmonary infection- 6p (4.4%) with good evolution; death from cardiovascular event- 2p (1.4%). A late evaluation using the ECKARDT score was performed in 65 patients up to 5 years after surgery, demonstrating positive results in 59p (90.7%), with a score up to 3. Thus, it is possible to conclude that there are advantages in EM due to the low incidence of immediate postoperative complications with good resolution and in the long term due to the absence of symptoms in most patients.
