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Crema et al. Minimally invasive esophagectomy in achalasia

cancer [2,3] secondary to stasis, chronic esophagitis, stomach as the plasty organ. In Brazil, resection of the
intraesophageal pH changes , and the presence of esophageal mucosa is preferentially performed for the
[4]
bacteria and viruses such as human papilloma virus treatment of advanced megaesophagus, in which a
[5]
(HPV) , in addition to a high prevalence of Helicobacter muscular tube is preserved through which the stomach
[6]
pylori in the esophageal mucosa . is transposed to the cervical region [23] .
[7]
Esophagectomy for the treatment of advanced In cases of advanced and recurrent megaesophagus,
megaesophagus, consisting of right thoracotomy, minimally invasive transhiatal esophagectomy is an
laparotomy, and cervicotomy, was reported by Camara excellent surgical approach to eliminate dysphagia
Lopes and Ferreira-Santos in 1963. Also, in Brazil, and prevent pulmonary complications resulting from
DePaula et al. , Crema et al. and Crema et al. [10] bronchoaspiration and from the occurrence of tumors
[9]
[8]
published their first results of full laparoscopic transhiatal associated with chronic esophageal stasis.
esophagectomy for the treatment of megaesophagus,
including removal of a surgical specimen and METHODS
esophagogastric anastomosis through cervical incision.
As megaesophagus affects the myenteric plexus that During the study period, 660 patients were treated.
is located between the smooth muscle layers, subtotal Of these, 346 (52.42%) underwent Heller surgery
resection of the organ theoretically cures the disease combined with an antireflux valve, 231 (35.01%)
because striated muscles, which are not innervated underwent transhiatal esophagectomy, and 83 (12.57%)
by myenteric plexuses, predominate in the proximal underwent esophageal dilatation due to possible clinical
third. Analysis of radiologic-manometric correlations conditions for any surgical procedure.
showed an amplitude of esophageal body contraction
of < 20 mmHg in all cases radiologically classified Two hundred thirty-one patients, 152 (65.8%) men and
as megaesophagus grade IV and in 35.7% of cases 79 (34.2%) women, with a mean age of 52.46 (19-80)
classified as grade III, defined by us as functionally years, were treated for advanced megaesophagus at
advanced [11] . the Department of Surgery, School of Medicine, Federal
University, Uberaba, Brazil, between September 1996
In a study investigating 31,769 patients with achalasia and October 2016. Two hundred and ten patients
in the United States between 2003 and 2010, (90.91%) had chagasic megaesophagus and 21
esophagectomy was performed in 785 cases (2.5%), patients (9.09%) had idiopathic megaesophagus. The
with an associated intrahospital mortality rate of 1.96%, mean duration of the surgical procedure was 165 (100-
similar to that with endoscopic treatment (1.17%), 235) min, and all procedures were performed by the
and Heller myotomy was performed in 15,567 cases same team, with the responsible surgeon being one
(49.0%) [12] . Various authors recommend esophageal of the authors of the present study (Crema E). Of the
resection in the case of recurrence or persistence of 231 patients, 98 (42.43%) had undergone at least some
symptoms after Heller surgery [13-17] . Csendes et al. [18] type of esophagogastric transition surgery 8-20 years
reported poor results of Heller surgery in 20% of before the study. All patients received information
patients after 10 years of follow-up and in 35% after 20 about the surgical procedure to be performed, and
years. Furthermore, 4.5% of these patients developed the protocol was approved by the Ethics Committee
esophageal cancer. In a 15-year follow-up study of 448
patients after Heller surgery, Leeuwenburgh et al. [19] on Human Research of the School of Medicine of the
[9]
found epidermoid cancer in 2.7% and adenocarcinoma Federal University, Uberaba, Brazil .
in Barrett’s esophagus in 0.7%.
Surgical technique
Crema et al. observed changes in esophageal pH The patients were placed in the dorsal decubitus
[6]
(4 and 5) and a high prevalence of HPV subtypes 16 position on the operating table with the legs abducted.
and 18 in the mucosa of patients with megaesophagus. The surgeon was positioned between the legs, and
These subtypes are directly associated with epidermoid an assistant (camera), on the left side of the patient.
esophageal cancer [20] . The monitor, when there was only one, was positioned
on the right and at the head of the operating table.
Using a transhiatal approach in 94% of cases, Devaney et al. Five entry ports were used: 2 of 10 mm diameter and
[21]
observed mortality in 2%, complications in 30%, and 3 of 5 mm diameter. One of the 10-mm ports was
anastomosis dehiscence in 10% of cases, whereas situated in the midline between the xiphoid appendix
88% of the patients were satisfied with the procedure. and the navel for a 30° eyepiece and the other was
Molena and Yang [22] reported excellent results of using positioned in the left hemiclavicular line 5 cm from the
a transthoracic approach in esophagectomy and the costal margin (right hand of the surgeon). The 5-mm
Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017 161