Laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus following failed cardiomyotomy: experience of 11 patients.

INTRODUCTION: Laparoscopic myotomy is a widely used procedure and is now considered to be the treatment of choice for achalasia. Esophagectomy for achalasia is usually performed only for megaesophagus. We present our experiences with laparoscopic transhiatal esophagectomy for 'sigmoid' megaesophagus due to failed Heller's myotomy.

MATERIALS AND METHODS: We managed a total of 11 patients with megaesophagus in our institute from 1993 to 2007. Work-up included investigations included endoscopy, barium swallow, and manometry. Laparoscopic transhiatal esophagectomy with gastric pull through was successfully performed for all cases.

RESULTS: The mean operating time was 317.5 min, and the mean blood requirement was 525 ml. The mean duration between the first and second procedures was 13 months. Our overall failure rate for primary surgery (myotomy) was 3.1% and overall symptomatic improvement was achieved in 82% of patients. There were no conversions.

DISCUSSION: About 10% of postmyotomy patients will have recurrence, and 5% of them need reoperation. Laparoscopic esophagectomy for sigmoid esophagus is a formidable operation due to adhesions/fibrosis at the hiatal area. Dissection of the S-shaped esophagus in the thorax is quite tedious and an accurate knowledge of the shape and location of the megaesophagus preoperatively is vital. If performed in specialized centers, laparoscopic excision is safe and effective, utilizing all the benefits of minimal access.