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Crema et al. Minimally invasive esophagectomy in achalasia

negative pressure. Another important factor is that the demonstrated acid secretion in the stomach and
esophagogastric anastomosis remains in the cervical maintenance of gastric emptying when the vagus nerve
region, which is characterized by positive pressure, thus was preserved during esophagectomy. Preservation
preventing reflux of gastric juice into the esophagus of the vagus nerves also permits the maintenance of
and consequent esophagitis. The latter occurs in the parasympathetic irrigation of the stomach, reducing the
case of intrathoracic location of the anastomosis. rate of dehiscence in esophagogastric anastomoses.
Furthermore, maintenance of the control of gastric
DISCUSSION emptying by preserving the vagus nerves reduced the
rate of dumping episodes and diarrhea.
The minimally invasive technique is considered the
gold standard for the treatment of megaesophagus. The benefit of vagal integrity goes beyond the
In its early stages, modified Heller surgery combined maintenance of secretory function and gastric motility.
with a partial antireflux valve has been used with Several experimental studies have demonstrated
good results. In advanced stages of megaesophagus, the importance of integrity of the vagus nerves for
minimally invasive transhiatal esophagectomy has protection against bacterial translocation. Vagal
been the technique of choice in most centers in Brazil. nerve preservation significantly reduces infectious
complications [27] . Experimental studies have reported
Preoperative preparation is also of fundamental sepsis and faster death in vagotomized animals when
importance for good outcomes in these patients, compared to controls [28] . An increased degree of
who are usually malnourished and have pulmonary peritonitis and higher levels of inflammatory cytokines
alterations. Chagasic patients exhibit different types were also observed in vagotomized animals [29] .
of cardiac arrhythmias that should be corrected during
the preoperative period. Our standardized protocol Evidence of the physiological preservation of the
includes nutritional and pulmonary outpatient care for vagus nerves is obtained by measuring the levels of
this purpose. pancreatic peptide after stimulation. Banki et al.
[1]
observed a significant increase in pancreatic peptide
A standardized interdisciplinary protocol that comprises levels when the vagus nerve was preserved during
the preoperative, perioperative, and postoperative esophagectomy.
management of patients with megaesophagus is of
fundamental importance to obtain satisfactory results in The objective of not performing pyloroplasty or
the treatment of this disease. Zamuner et al. [25] evaluated pyloromyotomy is to avoid reflux of alkaline secretion
the use of standardized protocols by multidisciplinary from the duodenum to the stomach after gastric
teams in the state of São Paulo, and concluded transposition to the mediastinum, a region of negative
that the number of centers applying preestablished pressure, which would cause an increase in acid
multidisciplinary protocols is small. secretion from the stomach.

There is clear evidence that preservation of the vagus Crema et al. [30] compared patients undergoing
nerves permits maintenance of gastric emptying, acid esophagectomy with and without vagotomy. The results
secretion, and storage capacity of the stomach, as showed a significant increase in pancreatic peptide
well as long-term weight maintenance. The results levels after insulin-induced hypoglycemia in the group
of minimally invasive approaches are consistent with with preserved vagus nerve, which was not observed in
the reduced number of major complications and low vagotomized patients.
mortality rate.
Our sample of patients undergoing esophagectomy
Wang et al. observed atrophic gastritis in patients who included 21 patients (9.09%) with idiopathic
[4]
underwent gastroplasty after esophagectomy without megaesophagus for whom serology and polymerase
vagal nerve preservation. chain reaction results of esophageal tissues were
negative for Trypanosoma cruzi. In a study conducted
Anatomically, the vagus nerves exhibit 2 trunks in Campinas-SP in which only serology was used for
(83.4%); these trunks are separated in 26.7% of the diagnosis of Chagas disease, 21% of the patients
patients, a communication between them is detected had idiopathic megaesophagus [31] .
in 56.7%, and 1 or 2 bifurcations occur in only 13.3%
of patients [26] . Clinical and experimental studies have Esophagectomy with preservation of the vagal
reported several benefits of preserving the vagus trunks has been used for the treatment of chagasic
nerves. Using Congo red staining, Banki et al. megaesophagus, although denervation of the entire
[1]
164 Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017