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De Aquino et al. Esophageal mucosectomy in advanced achalasia

The aim of the treatment for achalasia is to relieve METHODS
dysphagia and avoid long-term complications of food
stasis. Surgical technique
Surgical technique follows standardization proposed
This study aims to describe the technique and results by Aquino .
[9]
of esophageal mucosectomy and endomuscular pull-
through for the treatment of advanced achalasia. Mucosal resection
Abdominal stage
History and indications The operation starts with a midline laparotomy from
[6]
Kirschner in 1914 pioneered the idea of esophageal the xiphoid process to 5 cm below the umbilicus
complete mucosectomy with muscular preservation flowed by dissection of the abdominal esophagus and
through invagination. The authors were concerned at division of vagi nerves. Longitudinal myotomy in the
that time about mediastinal hemorrhage and pleural anterior esophagus from the cardia to the hiatus and
lesions. They tried to strip the esophagus through circumferential dissection of the mucosa/submucosa
neck and abdomen incisions in dogs but the idea was in an extension 5 to 7 cm.
not popular and an adequate way of reconstructing
the tract with the stomach was not developed Cervical stage
simultaneously.
Left lateral cervicotomy following the anterior border

Latter, others proved the possibility of the technique of the sternocleidomastoideus from the sternum to
in humans showing acceptable results in patients with 10 cm upwards. Dissection of the esophagus free of
caustic stenosis, esophageal carcinoma and proximal the posterior and prevertebral fascia and trachea.
gastric cancer [7,8] . Longitudinal myotomy in the anterior esophagus
from 5 cm bellow the pharynx to the sternum and
[9]
Aquino pioneered the technique in Brazil, a circumferential dissection of the mucosa/submucosa
country with a large incidence of achalasia. The layer.
technique was employed in patients with advanced
megaesophagus since transhiatal esophagectomy Combined stage
may be associated to complications such as accidental After a cylindrical segment of mucosa is dissected
pleural lesion, tracheal injury and hemothorax [10-13] . free of the muscular in the abdomen and neck, a
Pleural and tracheal injury, as well as hemorrhage, small mucosectomy is made in the abdomen and
may occur during mediastinal dissection due to neck to allow the passage of a rectal tube upwards.
severe periesophagitis leading to adhesions between Cervical esophageal mucosa is circumferentially
the esophagus and mediastinal structures. It is also transected and tied to the rectal tube attached to a
well known that stasis esophagitis observed in end- long and resistant surgical thread to allow pulling the
stage disease predisposes to premalignant lesions replacement viscera to the neck. The mucosa is slowly
or even carcinoma [14-17] . Based on this premises, striped downwards and inverted in the abdomen. The
the idea of striping the esophageal mucosa and esophagus is completely sectioned at the level of the
submucosa through cervical and abdominal incisions esophagogastric junction and in the neck.
in the absence of thoracotomy came to mind.
Thus, premalignant lesions could be prevented and Digestive tract reconstruction
complications related to mediastinal esophageal Digestive tract was reconstructed in all patients with the
dissection avoided. stomach after division of the left gastric, gastroepiploic
and short vessels. Two different routes for stomach
We operated dogs as a preliminary study before transposition were used based on accessibility to
applying the technique in clinical practice [18] . the neck. The muscular tunnel was used in 81 (70%)
Posteriorly, human cadavers were dissected to patients while in 34 (30%) patients the retrosternal
show the feasibility of the operation. Our clinical route was the option [19] . Esophagogastrostomy was
experience started after this training and showed performed in the cervical level in all patients. Circular
[9]
good outcomes . Recently, a series of 115 cases stapler end-to-side esophagogastrostomy was done
was published depicting good results and less in 73 (63%) patients and manual end-to-side posterior
morbidity than a transmediastinal esophagectomy [19] . esophagogastrostomy in 42 (37%) patients [19] .
All patients had an end stage achalasia defined by A feeding jejunostomy was always added to the
diameter larger than 10 cm. procedure. Drains were left in the abdomen and neck.

168 Mini-invasive Surgery ¦ Volume 1 ¦ December 28, 2017