October 31, 2007
Esophagogastro-Roux-En-Y Jejunostomy: A Surgical Option in Recurrent Achalasia? Case Report and Review of the Literature
By Roa, Paul E Sesto, Mark E
Recurrent obstructive symptoms after cardiomyotomy for achalasia occur in approximately 10 per cent to 15 per cent of patients, but only some require reoperation. Reoperative procedures for achalasia vary, and in general, have less success in relieving symptoms than the initial procedure. We present the case of a 37-year-old male with a 15-year history of recurrent achalasia, with symptoms of heartburn and progressive dysphagia after meals. He underwent several esophageal dilatations, botox injections, and two transthoracic Heller myotomies before the transabdominal esophagogastro-Roux-en-Y jejunostomy was performed. This case represents another surgical option for management of the challenging problem of recurrent achalasia. ACHALASIA IS A PRIMARY esophageal motor disorder characterized by the absence of peristalsis and incomplete lower esophageal sphincter (LES) relaxation during swallowing. The incidence is 0.5 to 1/100,000 in the United States. Achalasia affects both genders equally, typically presenting between the ages of 20 to 50 years, although it can occur at all ages. There is no treatment that restores esophageal peristalsis and normalizes LES relaxation. Instead, treatment is directed at palliation of symptoms and reducing the resistance of the LES.1 Myotomy for esophageal achalasia was first proposed by Heller2 and later developed by Zaaijer,3 and has shown excellent results to relieve dysphagia associated with achalasia.Recurrent symptoms after cardiomyotomy occur in approximately 10 to 15 per cent of patients with only some requiring a reoperation.4, 5 Reoperative surgery has had less success than the original procedure,6 and some patients require esophageal resection with its inherent complications. A survey of the literature did not reveal any series where an esophagogastro-Roux-en-Y jejunostomy was performed to correct the recurrent distal esophageal obstruction seen in recurrent achalasia.
A 37-year-old male presented with a 15-year history of recurrent heartburn and progressive dysphagia after meals. His medical history included several esophageal dilatations and botox injections, as well as two transthoracic Heller myotomies over a 12-year span. He presented to our department with recurrent achalasia confirmed by esophageal manometry. An upper GI demonstrated a markedly dilated proximal esophagus and an approximate 3 to 4-cm narrowed area at the gastroesophageal (GE) junction measuring 6 mm in diameter (Fig. 1). The operative strategy was a transabdominal approach to repeat a myotomy or an esophagogastric cardioplasty. The operative findings demonstrated that the segment of the distal esophagus was very thin, without the typical esophageal thickness seen in primary achalasia patients. A repeat myotomy was neither technically feasible, nor dependable. A side-to-side esophagealfundic cardioplasty was planned. A 1 cm opening in the lateral esophagus left of the mid line was inadvertently made during mobilization of the distal esophageal GE junction and gastric fundus. A longitudinal esophagotomy was made from the dilated portion of the esophagus through the stenotic portion and onto the normal cardia of the stomach, carrying it through the 1 cm lateral opening. The lateral position of the esophagogastrotomy rendered the planned esophagogastric cardioplasty technically too difficult. Thus, a side- to-side esophagogastric-Roux-en-Y jejunostomy was made to open the GE junction and provide drainage similar to patching open a stenotic artery (Fig. 2). The distal Roux limb was brought up in a retrocolic fashion through the left mesocolon and allowed to lie along the esophagus and gastric opening. A longitudinal jejunotomy was made to accommodate the opening in the esophagus and stomach, and a side-to- side anastomosis was performed in two layers. The patient had no postoperative complications and was discharged home on postoperative day 4, tolerating a soft diet. Three weeks later, the patient presented with difficulty swallowing. An upper GI demonstrated a food bezoar in the distal esophagus with the GE junction now 1 cm in diameter (Fig. 3). An esophagogastroduodenoscopy was performed to successfully break up the food bezoar. The operated area was demonstrated to have an adequate intraluminal diameter. There were no ensuing complications and the patient did well, tolerated a normal diet, and had no further problems at 11 months after surgery.
FIG. 1. Radiographic features showing dilatation of the esophagus with narrowed of the GE junction in the patient with two previous Heller myotomies.
FIG. 2. Schematic illustration of esophagogastro-Roux-en-Y jejunostomy.
The etiology of esophageal achalasia remains uncertain. Any treatment is directed at the palliation of symptoms, such as dysphagia and chest pain on swallowing, but does not address the underlying pathology.7 The reasons for myotomy failure are difficult to determine; however, possible causes include the development of carcinoma, the presence of a preoperative decompensated "sigmoid- shaped" megaesophagus, gastroesophageal reflux, a tight fundoplication, and inadequate myotomy due to either incomplete sectioning of the muscle fibers or by healing with fibrosis of the myotomy edges.8 The appropriate management of these patients remains controversial, and includes endoscopie dilatation, botulinum toxin injection, another myotomy, cardioplasty with Roux-en-Y partial gastrectomy (Serra-Doria procedure),9 and esophagectomy. Reoperation for achalasia can correct postoperative dysphagia, however results are less successful than those after an adequate initial operation. Reoperative procedures for achalasia vary.
In 1961, Holt and Large10 suggested the use of Roux-en-Y partial gastrectomy to correct severe reflux esophagitis secondary to a Grondahl-type cardioplasty11 used initially for primary achalasia. In 1971, Serra-Doria et al.9 combined a long lateral anastomosis extending through the esophagus into the gastric fundus (Grondahl- type cardioplasty) to facilitate esophageal emptying and a Roux-en- Y partial gastrectomy to prevent bile reflux for initial treatment of patients with Chagas' megaesophagus. In 1986, Ellis and colleagues12 reported 46 patients with recurrent achalasia. The most common procedures were an esophagomyotomy or extension of a previously performed myotomy, performed on 19 patients with recurrent achalasia. In one patient, in addition to the myotomy, the redundant sigmoid portion of the esophagus was excised and the cut ends of the esophagus were anastomosed. Nine patients with severe reflux with peptic stricture underwent cardiectomy and antrectomy with esophagogastrostomy and Roux-en-Y gastrojejunostomy. Takedown or modification of a previously performed antireflux procedure was performed in nine patients. They concluded that to achieve good results after reoperative procedures, the preoperative diagnosis must be accurate and the operation should be performed before the development of megaesophagus. The best results were obtained by takedown of a previous wrap and resections.
FIG. 3. Postoperative Upper GI showing findings of large filling defect at the distal esophagus.
Some authors have also suggested that extensive esophagectomy should be considered to relieve esophageal obstruction and restore normal alimentation in patients with megaesophagus or prior esophagomyotomy.13-18 In 1995, Miller et al.16 reported 37 patients who underwent esophageal resection after initial surgical treatment for achalasia. Reconstruction was established with the stomach in 26 patients, colon in 6, and small bowel in 5. To determine if the type of resection and reconstruction significantly affected morbidity, mortality, or long-term functional outcome, they divided the 37 patients into five groups: transhiatal esophagogastrectomy (9 patients); transthoracic esophagogastrectomy (12 patients); extended transthoracic esophagogastrectomy (5 patients); distal esophageal resection, antrectomy, and Roux-en-Y gastrojejunostomy (5 patients); and colonie interposition (6 patients). A significant increase in the amount of blood loss and number of transfusions was observed in the transhiatal esophagogastrectomy. Also, a significant increase in the number of intra-operative complications (44%) with a mortality of 5.4 per cent occurred in this group. They concluded that transhiatal resection is associated with increased morbidity and mortality.
Peters and coworkers17 performed esophageal re section through a right thoracotomy with colon interposition for 19 patients with end- stage achalasia. They reported complications in four patients (21%). Two of these patients required reoperation: one for postoperative bleeding and one for management of a chylothorax. The functional results have been excellent in most patients and there was no mortality. In 2001, Devaney et al.18 reported their experience in 93 patients with previous esophagomyotomy for megaesophagus; 94 per cent of patients underwent a transhiatal esophagectomy. The stomach was used as the esophageal substitute in 91 per cent of cases. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). In all, 95 per cent of patients eat well, 50 per cent have required an anastomotic dilatation, and 4 per cent have refractory postvagotomy dumping. Hsu and colleagues19 presented a retrospective study of nine patients with recurrent symptoms of achalasia. The patients underwent gastric cardiectomy, distal esophagectomy, and replacement with a 30-cm short-colon interposition through a left thoracoabdominal approach. One patient had early intestinal strangulation with graft failure. Takedown of the graft and end-toside esophagogastrostomy were successful. In most patients, overall patient satisfaction was good and they could tolerate a regular diet. The authors concluded that limited distal esophagectomy, with short-colon interposition through a left thoracoabdominal approach, is a safe and feasible alternative to near total esophagectomy in patients who have had prior failed esophagomyotomy. Conclusion
Technically, the esophagogastro-Roux-en-Y jejunostomy is a relatively simple procedure and is easily modified to accommodate various lengths of distal esophageal strictures. In addition, well- vascularized tissue can be imported into a hostile surgical environment, functioning as a "living patch." Finally, the procedure does not "burn bridges" or otherwise limit the future surgical options available, should this procedure fail.
The esophagogastro-Roux-en-Y jejunostomy is another surgical option for the treatment of recurrent achalasia. Although this is an isolated case report with short-term follow-up, it demonstrates utility, particularly in those patients before the development of endstages recurrent achalasia with mega-esophagus.
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PAUL E. ROA, M.D., MARK E. SESTO, M.D., F.A.C.S.
From the Department of General and Vascular Surgery, Cleveland Clinic Florida, Weston, Florida
Address correspondence and reprint requests to Mark E. Sesto, Chairman, Department of General and Vascular Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331. E- mail: firstname.lastname@example.org.
Copyright Southeastern Surgical Congress Sep 2007
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