Devaney E J, Lannettoni M D, Orringer M B, Marshall B
Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109, USA.
Ann Thorac Surg. 2001 Sep;72(3):854-8. doi: 10.1016/s0003-4975(01)02890-9.
In 1989, we predicted an increasing number of esophagectomies for megaesophagus and for recurrent symptoms after prior esophagomyotomy or balloon dilatation for achalasia. Patient selection in this group is challenging, as the potential operative morbidity of an esophagectomy must be weighed against the expected clinical outcome after a redo esophagomyotomy or alternative procedures designed to salvage the native esophagus.
The hospital records of 93 patients undergoing esophagectomy for achalasia during the past 20 years were reviewed retrospectively and the results of operation assessed using our prospectively established Esophageal Resection Database and follow-up information obtained through personal contact with the patients.
Patient age averaged 51 years. Indications for esophagectomy included tortuous megaesophagus (64%), failure of prior myotomy (63%), and associated reflux stricture (7%). Ninety-four percent of the patients underwent a transhiatal esophagectomy. Stomach was used as the esophageal substitute in 91% cases. Intraoperative blood loss averaged 672 mL. Postoperative length of stay averaged 12.5 days. Major complications included anastomotic leak (10%), recurrent laryngeal nerve injury (5%), delayed mediastinal bleeding requiring thoracotomy (2%), and chylothorax (2%). There were 2 hospital deaths (2%) from respiratory insufficiency and sepsis. Follow-up has averaged 38 months. In all, 95% of patients eat well; nearly 50% have required an anastomotic dilatation; troublesome regurgitation has been rare; and 4% have refractory postvagotomy dumping.
Esophagectomy, preferably through a transhiatal approach, is generally safe and effective therapy in selected patients with achalasia. Unique technical considerations include difficulty encircling the dilated cervical esophagus, deviation of the esophagus into the right chest, large aortic esophageal arteries, and adherence of the exposed esophageal submucosa to the adjacent aorta after prior myotomy.
1989年，我们预测因巨食管以及既往贲门失弛缓症行食管肌层切开术或球囊扩张术后复发症状而行食管切除术的病例数会增加。该组患者的选择具有挑战性，因为必须权衡食管切除术潜在的手术并发症与再次食管肌层切开术或旨在挽救原生食管的替代手术预期的临床结果。
回顾性分析过去20年间93例因贲门失弛缓症接受食管切除术患者的医院记录，并使用我们前瞻性建立的食管切除数据库及通过与患者个人联系获得的随访信息评估手术结果。
患者平均年龄51岁。食管切除术的指征包括迂曲的巨食管（64%）、既往肌层切开术失败（63%）以及相关的反流性狭窄（7%）。94%的患者接受了经胸食管切除术。91%的病例使用胃作为食管替代物。术中平均失血量为672毫升。术后平均住院时间为12.5天。主要并发症包括吻合口漏（10%）、喉返神经损伤（5%）、需要开胸的延迟性纵隔出血（2%）和乳糜胸（2%）。有2例（2%）患者因呼吸功能不全和脓毒症死亡。平均随访38个月。总体而言，95%的患者进食良好；近50%的患者需要进行吻合口扩张；严重反流很少见；4%的患者有难治性迷走神经切断术后倾倒综合征。
对于选定的贲门失弛缓症患者，食管切除术，最好是经胸入路，通常是安全有效的治疗方法。独特的技术考虑因素包括环绕扩张的颈段食管困难、食管向右胸偏移、粗大的主动脉食管动脉以及既往肌层切开术后暴露的食管黏膜下层与相邻主动脉粘连。
