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Minimally Invasive Surgical Treatment of Sigmoid Esophagus in Achalasia
Matthew J. Schuchert*, James D. Luketich, Arman Kilic, Rodney J. Landreneau, Miguel Alvelo - Rivera, Neil a. Christie, Sebastien Gilbert, Arjun Pennathur
Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh, Pittsburgh, PA

Background: The surgical management of the sigmoid esophagus in the setting of achalasia is controversial. The objective of this study is to review our experience with the minimally invasive surgical management of the achalasia patient with a sigmoid esophagus.
Methods: We searched the records of achalasia patients (n=207) who underwent minimally invasive surgery at our institution from 1992 - 2005, and identified those with a sigmoid esophagus (n=26). The outcome variables analyzed were perioperative morbidity and mortality, symptomatic improvement, requirement for further postoperative surgical interventions and the factors associated with failure. Patients underwent preoperative esophagogastroduodenoscopy, barium esophagram and manometry.
Results: A total of 26 achalasia patients (16 men; and 10 women) underwent minimally invasive myotomy (MIM; n=22) or minimally invasive esophagectomy (MIE; n=4) as primary surgical therapy for sigmoid esophagus. The median age was 57.5 years (range 25 - 83). There was no conversion to open surgery in either group. Peri-operative mortality was zero. Median hospital stay was 3 and 7 days in the MIM and MIE groups, respectively. There were 4 complications (18.2%; 2 - pneumonia, 2 - pneumothorax) in the MIM group and 3 complications (75%; 1 - anastamotic leak, 1 - pleural effusion, 1 - hemothorax) in the MIE group. Mean dysphagia score (1= no dysphagia,5=unable to swallow saliva) improved from 3.05 to 1.58 following MIM or MIE (p<0.001). At a mean follow-up of 27.7 months, eight (36.4%) patients undergoing primary MIM required further surgical interventions (re-do myotomy (n=1) or esophagectomy (n=7)). No further surgical interventions were required in the MIE group. There was a trend towards a longer duration of symptoms in those requiring further surgery after primary myotomy (mean 26.6 years vs. 13.9 years who did not require re-do surgery) (p=0.067). All patients (8/8; 100%) requiring re-do surgery had prior endoscopic treatment (Botulinum toxin injection or dilatation), whereas 10 /14 patients (71.4%) with successful MIM had prior endoscopic therapy (p=NS).
Conclusions: MIM results in symptomatic improvement in a majority of achalasia patients with a sigmoid esophagus, with a failure rate of 36% on longer follow-up. The duration of symptoms may be a preoperative indicator for the need for further surgical intervention in patients following primary MIM. MIE offers similar symptom relief with a more durable long term success, however may be associated with a higher morbidity. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients.

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