HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Albert Amin Sader Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sader, A. A. Search for Related Content PubMed PubMed Citation Articles by Sader, A. A.

J Thorac Cardiovasc Surg 2000;119:194-195
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Esophagectomy with gastric reconstruction for achalasia

Head, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Faculty of Medicine of Ribeirão, University of São Paulo
14048-900 Ribeirão Preto, São Paulo, Brazil

To the Editor:

I read with great interest the article by Banbury and associates, titled "Esophagectomy With Gastric Reconstruction for Achalasia" (J Thorac Cardiovasc Surg 1999;117:1077-85).

In our department, we have been performing esophagectomy with gastric reconstruction for the treatment of megaesophagus due to Chagas disease since 1956. As proposed by Câmara-Lopes and Ferreira-Santos, ¹ the operation was performed in 2 stages, with the stomach brought up by the retrosternal route. Since 1961, Ruy E. Ferreira-Santos and I have been performing a 1-stage operation, leaving the stomach in the bed of the resected esophagus. ² Because thoracotomy, laparotomy, and cervicotomy were required at the time, I devised a rotary surgical table ³ that permitted easy and rapid changes in decubitus, making it possible to always operate in the best position. Starting in 1985, whenever possible, we began to perform the operation without thoracotomy.

Because of the denervation occurring in Chagas disease, an association of megaesophagus with megacolon was found in 76% of cases, and this is the reason that the colon was never used. However, the stomach can also have varied degrees of denervation and dilatation, which worsened by surgery. This was probably the cause of the stasis and regurgitation observed in a few cases in our series. This complication was so severe in 1 patient that 3 years later he regurgitated everything he ate, with severe impairment of his nutritional status. to solve this difficult problem, we successfully performed a Roux-en-Y transdiaphragmatic gastrojejunal shunt. Perhaps esphagectomy with gastric reconstruction should not be performed in patients with a greatly dilated stomach. Like the authors, we believe that pyloroplasty is imperative to avoid gastric stasis and regurgitation.

There was also a frequent association of advanced chagasic megaesophagus with carcinoma (3%), ulcers, and leukoplastic lesions. These findings support the indication of esophagectomy. ⁴ Another frequent postoperative complication in our cases (12%), not reported by the authors, is diarrhea of varying intensity, which tends to disappear with time. In some patients, diarrhea was accompanied by lower limb edema, suggesting a state of nutritional deficiency. However, protein levels, as well as glucose and fat absorpiton tests, were within normal limits. The only alteration found was achlorhydria or hypochlorhydria. Fistulas and stenosis, relatively frequent in 2-stage operations, became less common in 1-stage operations. Wide anastomoses were performed without tension on a single plane with separate stitches of 4-0 polypropylene sutures. In shorter stomachs, mobilization of the duodenum by the Kocher maneuver permits easier ascension of the gastric fundus to the neck. One case of bleeding ulcer and 2 cases of carcinoma occurred in transposed stomachs.

The association with Chagas heart disease is frequent, and some of these patients have arrhythmias that require careful study for accurate diagnosis. In our service, we showed that atrial recordings and stimulation can be performed through the transposed stomach in the posterior mediastinum. This noninvasive examination provides better evaluation of the patient.

Successful generations of surgeons have operated on more than 200 patients with an overall mortality of 3%. Most deaths occurred during the early period of the series.

In conclusion, we believe that 1-stage esophagectomy with gastric reconstruction through the posterior mediastinum is currently the best treatment option for advanced (grade IV) chagasic megaesophagus. The performance of this technique with the aid of video surgery, already available, will simplify the procedure and make the postoperative period less painful.

References

1. Câmara-Lopes LH, Ferreira-Santos R. Selective indication of the Heller operation: partial resection and subtotal resection of the esophagus in the surgical treatment of the megaesophagus (in Portugese). Rev Paul Med 1958;52:269-75.
   
2. Ferreira-Santos R. Surgical treatment of esophageal aperistalsis (megaesophagus). Thesis presented to the Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil, 1963 (in Portugese).
   
3. Sader AA. Laterally rotating surgical device for one-stage operations on the thorax and abdomen. Am J Surg 1983;145:420-3.[Medline]
   
4. Câmara-Lopes LH. Carcinoma of the esophagus as a complication of megaesophagus. Am J Dig Dis 1961;6:742-56.[Medline]
   

This article has been cited by other articles:

				E. Crema, L. B.P. Ribeiro, J. A. Terra Jr, and A. A. Silva Laparoscopic Transhiatal Subtotal Esophagectomy for the Treatment of Advanced Megaesophagus Ann. Thorac. Surg., October 1, 2005; 80(4): 1196 - 1201. [Abstract] [Full Text] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Albert Amin Sader Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sader, A. A. Search for Related Content PubMed PubMed Citation Articles by Sader, A. A.