Efficacy of laparoscopic cardiectomy combined with side overlap anastomosis for the treatment of terminal achalasia

Abstract

To investigate the safety and short-term effectiveness of laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction for the treatment of terminal or end-stage achalasia, patients with end-stage achalasia treated with laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction were retrospectively enrolled. The clinical data, surgical data and follow-up were analyzed. Among twenty-five patients enrolled, the achalasia type St was present in 12 (48%) patients, type Sg in 9 (36%), and type aSg in 4 (16%). The surgical time ranged 60-180 min (median 100 min) with an intraoperative blood loss 20-200 ml (median 50 ml). Five (20%) patients experienced complications within a week after surgery, with fever (> 38.5 ℃) in two (40%) patients within 3 days after surgery, abdominal incision infection in one (20%), and anastomotic leak in two (40%). The postoperative hospitalization time ranged 8-44 (median 10) days. Follow-up was conducted 6-38 months (median 16) after surgery. Compared with the preoperative Eckardt score (7.64 ± 1.32), the Eckardt score was significantly (P < 0.01) decreased at one month (0.52 ± 0.87), 6 (0.84 ± 1.11) and 12 (1.23 ± 1.23) months after surgery in all patients. The Eckardt score in type St was significantly (P < 0.05) smaller than in type Sg or aSg at 6 and 12 months after surgery. Seven patients maintained an Eckardt score 0 with complete relief of their symptoms. The effective rate was 100% for type St, 88.8% for type Sg, and 75% for type aSg. The effective rates at 1 month, 6 and 12 months after surgery were 100% (95% CI: 100% -100%), 96% (95% CI: 87.7 -100%), and 92% (95% CI: 80.6 -100%). Two patients were diagnosed with gastroesophageal reflux disease (GERD) at the end of the follow-up. The cumulative incidence of GERD at 1 month, 6 and 12 months after surgery was 0, 4% (95% confidence interval or CI: 0-12.3%), and 8% (95% CI: 0-19.4%). In conclusion, the laparoscopic-assisted cardiectomy with side-overlap esophagogastric reconstruction is safe and effective for the treatment of end-stage achalasia, and the effect is significantly better for achalasia type St than for types Sg and aSg.

Keywords: Achalasia; Effectiveness; End stage; Laparoscopic-assisted cardiectomy; Side-overlap esophagogastric reconstruction.

Fig. 1

Classification of achalasia: Type St (left), Sg (middle), and aSg (right).

Fig. 2

Surgical Steps. A&B. The esophagus was severed. C&D. The cardia was broken off. E. The residual end of the esophagus and the opening of the residual stomach were shown. F&G. A linear cutting closer was sent into the opening of the residual stomach and rotated counterclockwise. H. The opening of the residual stomach was closed. I. The lower segment of the esophagus was fixed.

Fig. 3

Cumulative gastroesophageal reflux disease (GERD) risk after surgery.