ADVANCED MEGAESOPHAGUS TREATMENT: WHICH TECHNIQUE OFFERS THE BEST RESULTS? A SYSTEMATIC REVIEW

CHAIB, Paulo Sérgio; TEDRUS, Gloria de Almeida; AQUINO, José Luís Braga de; MENDONÇA, José Alexandre

doi:10.1590/0102-6720202400016e1809

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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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Review Article • ABCD, arq. bras. cir. dig. 37 • 2024 • https://doi.org/10.1590/0102-6720202400016e1809 copy

ADVANCED MEGAESOPHAGUS TREATMENT: WHICH TECHNIQUE OFFERS THE BEST RESULTS? A SYSTEMATIC REVIEW

TRATAMENTO DO MEGAESÔFAGO AVANÇADO: QUAL TÉCNICA OFERECE MELHORES RESULTADOS? UMA REVISÃO SISTEMÁTICA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Advanced megaesophagus predisposes to risks of malnutrition infections and cancer, in addition to having a significant impact on quality of life. There is currently no consensus in the literature regarding the best surgical option for advanced megaesophagus, although there is a predilection for esophagectomy, despite this surgery being associated with significant morbidity and mortality. Other surgical procedures, such as esophageal mucosectomy and Heller cardiomyotomy, have been proposed with good results.

AIMS:

To conduct a systematic review and meta-analysis of the literature on the surgical treatment of advanced megaesophagus.

METHODS:

Databases used included PubMed, Latin American and Caribbean Health Sciences Literature (Lilacs), Embase and Medical Literature Analysis and Retrieval System Online (MedLine), as well as reference research. Two reviewers selected the articles independently.

RESULTS:

A total of 14 articles were chosen, which included 1,862 patients. The studies were divided into two groups: laparoscopic cardiomyotomy with fundoplication (213 patients) and major surgeries (1,649 patients). The studies yielded mostly good or excellent results regarding late outcomes in both groups. However, there was significant morbidity associated with the major surgeries group.

CONCLUSIONS:

Laparoscopic Heller myotomy can be performed on patients with advanced megaesophagus, with lower rates of complications and mortality compared to major surgeries, with reservations regarding late outcomes results.

HEADINGS:
Esophageal Achalasia; Digestive System Surgical Procedures; Esophagectomy; Myotomy; Treatment Outcome; Systematic Review

Data base	Articles found	Selected articles
Data base	n	n
PubMed	127	2
MEDLINE	260	2
Lilacs	247	3
Others	11	6
Total	969	14

Study	Study design	Treatment carried out	No. of patients	Average age (years)	Gender (M/F)	Classification of achalasia
Panchanatheeswaran et al.²⁶26. Panchanatheeswaran K, Parshad R, Rohila J, Saraya A, Makharia GK, Sharma R. Laparoscopic Heller’s cardiomyotomy: a viable treatment option for sigmoid oesophagus. Interact Cardiovasc Thorac Surg. 2013;16(1):49-54. https://doi.org/10.1093/icvts/ivs427 https://doi.org/10.1093/icvts/ivs427...	Retrospective cohort	Laparoscopic Heller cardiomyotomy + antireflux procedure	8	39.5	M50% F50%	“Sigmoid esophagus”
Pantanali et al.²⁷27. Pantanali CA, Herbella FA, Henry MA, Farah JFM, Patti MG. Laparoscopic Heller myotomy and fundoplication in patients with Chagas’ disease achalasia and massively dilated esophagus. Am Surg. 2013;79(1):72-5. PMID: 23317615.	Retrospective cohort	Laparoscopic Heller cardiomyotomy + Pain fundoplication	11	56	M6 F5	>10 cm (diameter)
Simić et al.³¹31. Simić AP, Skrobić OM, Velicković D, Ražnatović Z, Šaranović D, Šljukić V, et al. Minimally invasive surgery for benign esophageal disorders: first 200 cases. Eur Surg. 2015;47(1):25-34. https://doi.org/10.1007/s10353-015-0296-x https://doi.org/10.1007/s10353-015-0296-...	Retrospective cohort	Laparoscopic Heller-Dor cardiomyotomy	10	51	-	“Sigmoid esophagus”
Rosemurgy et al.²⁹29. Rosemurgy A, Downs D, Luberice K, Rodriguez C, Swaid F, Patel K, et al. Laparoscopic heller myotomy with anterior fundoplication improves frequency and severity of symptoms of achalasia, regardless of preoperative severity determined by esophagography. Am Surg. 2018;84(2):165-73. PMID: 29580341.	Retrospective cohort	Laparoscopic Heller cardiomyotomy + anterior fundoplication	10 III: 3 IV: 7	III: 61 IV 56	III: M0M3 IV: F4M3	III: >6 cm, IV: >3 esophageal curves and >6 cm (diameter)
Costantini et al.⁷7. Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, et al. A thousand and one laparoscopic Heller myotomies for esophageal achalasia: a 25-year experience at a single tertiary center. J Gastrointest Surg. 2019;23(1):23-35. https://doi.org/10.1007/s11605-018-3956-x https://doi.org/10.1007/s11605-018-3956-...	Retrospective cohort	Laparoscopic Heller-Dor cardiomyotomy	142 III: 87 IV: 55	46	-	grade III: >6cm (diameter) grade IV: “sigmoid-shaped esophagus”
Tassi et al.³³33. Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, et al. Quality of life after operation for end-stage achalasia: pull-down Heller-Dor versus esophagectomy. Ann Thorac Surg. 2022;113(1):271-8. https://doi.org/10.1016/j.athoracsur.2020.12.048 https://doi.org/10.1016/j.athoracsur.202...	Retrospective cohort	Laparoscopic Heller-Dor “Pull-down” cardiomyotomy (CLH) x Esophagectomy (E)	CLH: 32	CLH: 57	CLH: M34.37% F65.62%	“End-stage achalasia”

Study	Complications/morbidity	Mortality	Length of stay (days)	Average follow-up time	Late results
Panchanatheeswaran et al.²⁶26. Panchanatheeswaran K, Parshad R, Rohila J, Saraya A, Makharia GK, Sharma R. Laparoscopic Heller’s cardiomyotomy: a viable treatment option for sigmoid oesophagus. Interact Cardiovasc Thorac Surg. 2013;16(1):49-54. https://doi.org/10.1093/icvts/ivs427 https://doi.org/10.1093/icvts/ivs427...	Morbidity 0% 1 iatrogenic intraoperative complication	None	4.25	19.5 months	100% Excellent or Good (50–50%)
Pantanali et al. ²⁷27. Pantanali CA, Herbella FA, Henry MA, Farah JFM, Patti MG. Laparoscopic Heller myotomy and fundoplication in patients with Chagas’ disease achalasia and massively dilated esophagus. Am Surg. 2013;79(1):72-5. PMID: 23317615.	Morbidity 0%	None	1	31.5 months	72.8% Excellent or Good
Simić et al.³¹31. Simić AP, Skrobić OM, Velicković D, Ražnatović Z, Šaranović D, Šljukić V, et al. Minimally invasive surgery for benign esophageal disorders: first 200 cases. Eur Surg. 2015;47(1):25-34. https://doi.org/10.1007/s10353-015-0296-x https://doi.org/10.1007/s10353-015-0296-...	Morbidity 0% 1 mucosal perforation 1 trocar bleeding 1 wound infection	None	2	28 months	94.4% resolution of dysphagia
Rosemurgy et al.²⁹29. Rosemurgy A, Downs D, Luberice K, Rodriguez C, Swaid F, Patel K, et al. Laparoscopic heller myotomy with anterior fundoplication improves frequency and severity of symptoms of achalasia, regardless of preoperative severity determined by esophagography. Am Surg. 2018;84(2):165-73. PMID: 29580341.	Intraoperative: 0 Postoperative period: 1 (atelectasia)	None	III: 4 IV: 3	27 months	III: 33% Excellent 66% Good IV: 25% Excellent 75% Good
Costantini et al.⁷7. Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, et al. A thousand and one laparoscopic Heller myotomies for esophageal achalasia: a 25-year experience at a single tertiary center. J Gastrointest Surg. 2019;23(1):23-35. https://doi.org/10.1007/s11605-018-3956-x https://doi.org/10.1007/s11605-018-3956-...	Morbidity 4.7% 22 mucosal perforations 1 splenic injury 2 Trocar bleeding	0.1% (AMI)	-	62 months	89.5% Good outcome III: 90.8% IV 76.4% Failure: III 9.2% IV 23.6%
Tassi et al.³³33. Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, et al. Quality of life after operation for end-stage achalasia: pull-down Heller-Dor versus esophagectomy. Ann Thorac Surg. 2022;113(1):271-8. https://doi.org/10.1016/j.athoracsur.2020.12.048 https://doi.org/10.1016/j.athoracsur.202...	CLH: 12.5% 1 mucous fistula 1 mucous membrane 1 hyper-dysphagia 1 hyper competent fundoplication	There were none in both groups	CLH: 6	CLH: 68 months	CLH: 46.87% Excellent 34.37% Good

Study	Study design	Treatment carried out	No. of patients	Average age (years)	Gender (M/F)	Classification of achalasia
Molena et al.¹⁸18. Molena D, Mungo B, Stem M, Feinberg RL, Lidor AO. Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg. 2014;18(2):310-7. https://doi.org/10.1007/s11605-013-2318-y https://doi.org/10.1007/s11605-013-2318-...	Retrospective cohort	Esophagectomy	963	54.6	M49.01% F50.99%	-
Felix et al.¹⁰10. Felix VN, Yogi I, Martins CEN, Padrão EMH, Silva AGM, Faria KVM. Maximizing results of esophagectomy for advanced achalasia. Available from: http://www.valterniltonfelix.com.br/pdf/medicina/profissionais/Artigo-14.pdf. Assessed: Jan. 25, 2016. http://www.valterniltonfelix.com.br/pdf/...	Case series	Transhiatal esophagectomy	11	44	M8 F3	“sink trap megaesophagus”
Oliveira et al.²⁰20. Oliveira GC, Rocha RLB, Coelho-Neto JS, Terciotti-Junior V, Lopes LR, Andreollo NA. Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus. Arq Bras Cir Dig. 2015;28(1):28-31. https://doi.org/10.1590/S0102-67202015000100008 https://doi.org/10.1590/S0102-6720201500...	Retrospective cohort	Transhiatal esophagectomy (THE) x Mucosectomy (ME)	40 THE: 23 ME: 17	-	-	Advanced megaesophagus
Aquino et al.⁴4. Aquino JLB, Said MM, Pereira DAR, Leandro-Merhi VA, Nascimento PC, Reis VV. Early and late assessment of esophagocardioplasty in the surgical treatment of advanced recurrent megaesophagus. Arq Gastroenterol. 2016;53(4):235-9. https://doi.org/10.1590/S0004-28032016000400005 https://doi.org/10.1590/S0004-2803201600...	Retrospective cohort	Serra-Doria esophagocardioplasty	19	63 a 78	M14 F5	Grades III and IV (Rezende Classification)
Aquino et al.²2. Aquino JLB, Said MM, Pereira DAR, Machado FR, Ramos JPZ, Brandi Filho LA, et al. Análise comparativa da mucosectomia esofágica e da esofagectomia transmediastinal no tratamento do megaesôfago avançado: estudo comparativo em 229 pacientes. Anais do 32o Congresso Brasileiro de Cirurgia; 2017; Brasília. Brasília: CBC; 2017.	Retrospective cohort	Esophageal mucosectomy (ME) x Transhiatal esophagectomy (THE)	229 ME: 115 THE: 114	15-76 years	M70.3% F29.7%	Advanced megaesophagus
Crema et al.⁸8. Crema E, Terra Júnior JA, Borges MA, Queiroz CAS, Soares LA, da Silva AA. Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy. Acta Cir Bras. 2018;33(9):834-41. https://doi.org/10.1590/s0102-865020180090000012 https://doi.org/10.1590/s0102-8650201800...	Cohort	Transhiatal VLP esophagectomy with vagus nerve preservation	136	59.3	M59.5% F40.45%	Advanced megaesophagus
Fontan et al.¹¹11. Fontan AJA, Batista-Neto J, Pontes ACP, Nepomuceno MC, Muritiba TG, Furtado RS. Esofagectomia minimamente invasiva laparoscópica vs. esofagectomia trans-hiatal aberta no megaesôfago avançado: estudo randomizado. ABCD Arq Bras Cir Dig. 2018;31(3):e1382. https://doi.org/10.1590/0102-672020180001e1382 https://doi.org/10.1590/0102-67202018000...	Randomized clinical trial	Open transhiatal esophagectomy vs. VLP	30 open: 15 VLP: 15	open: 47.2 VLP: 44.1	open: M8 F7 VLP: M11 F14	Grades III and IV (Rezende Classification)
Torres-Landa et al.³⁴34. Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical outcomes after esophagectomy in patients with achalasia: a NSQIP matched analysis with non-achalasia esophagectomy patients. J Gastrointest Surg. 2021;25(10):2455-62. https://doi.org/10.1007/s11605-021-05056-4 https://doi.org/10.1007/s11605-021-05056...	Retrospective cohort	Esophagectomy (E)	209	56	M51.8% F48.2%	-
Tassi et al.³³33. Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, et al. Quality of life after operation for end-stage achalasia: pull-down Heller-Dor versus esophagectomy. Ann Thorac Surg. 2022;113(1):271-8. https://doi.org/10.1016/j.athoracsur.2020.12.048 https://doi.org/10.1016/j.athoracsur.202...	Retrospective cohort	Laparoscopic Heller-Dor “Pull-down” cardiomyotomy (CLH) x Esophagectomy (E)	E: 12	E: 59	E: M62.5% F37.5%	“End-stage achalasia”

Study	Complications/morbidity	Mortality	Length of stay (days)	Average follow-up time	Late results
Torres-Landa et al.³⁴34. Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical outcomes after esophagectomy in patients with achalasia: a NSQIP matched analysis with non-achalasia esophagectomy patients. J Gastrointest Surg. 2021;25(10):2455-62. https://doi.org/10.1007/s11605-021-05056-4 https://doi.org/10.1007/s11605-021-05056...	Morbidity 43.5% Readmission 2.2% Reoperation 6.7% Sepsis 9.5% Pneumonia 12.4% Blood transfusion 20.5%	None	10	1 month	Not assessed
Tassi et al.³³33. Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, et al. Quality of life after operation for end-stage achalasia: pull-down Heller-Dor versus esophagectomy. Ann Thorac Surg. 2022;113(1):271-8. https://doi.org/10.1016/j.athoracsur.2020.12.048 https://doi.org/10.1016/j.athoracsur.202...	E: 43.75% 3 anastomosis fistulas 1 pyloroplasty fistula 1 pleural empyema 1 acute respiratory failure	There were none in both groups	E: 23	E: 61 months	E: 37.5% excellent 25% good

Study	Risk of bias domains
Study	D1	D2	D3	D4	D5	D6	D7	Overall
Rosemurgy et al.²⁹29. Rosemurgy A, Downs D, Luberice K, Rodriguez C, Swaid F, Patel K, et al. Laparoscopic heller myotomy with anterior fundoplication improves frequency and severity of symptoms of achalasia, regardless of preoperative severity determined by esophagography. Am Surg. 2018;84(2):165-73. PMID: 29580341.
Fontan et al.¹¹11. Fontan AJA, Batista-Neto J, Pontes ACP, Nepomuceno MC, Muritiba TG, Furtado RS. Esofagectomia minimamente invasiva laparoscópica vs. esofagectomia trans-hiatal aberta no megaesôfago avançado: estudo randomizado. ABCD Arq Bras Cir Dig. 2018;31(3):e1382. https://doi.org/10.1590/0102-672020180001e1382 https://doi.org/10.1590/0102-67202018000...
Pantanali et al.²⁷27. Pantanali CA, Herbella FA, Henry MA, Farah JFM, Patti MG. Laparoscopic Heller myotomy and fundoplication in patients with Chagas’ disease achalasia and massively dilated esophagus. Am Surg. 2013;79(1):72-5. PMID: 23317615.
Torres-Landa et al.³⁴34. Torres-Landa S, Crafts TD, Jones AE, Dewey EN, Wood SG. Surgical outcomes after esophagectomy in patients with achalasia: a NSQIP matched analysis with non-achalasia esophagectomy patients. J Gastrointest Surg. 2021;25(10):2455-62. https://doi.org/10.1007/s11605-021-05056-4 https://doi.org/10.1007/s11605-021-05056...
Aquino et al.⁴4. Aquino JLB, Said MM, Pereira DAR, Leandro-Merhi VA, Nascimento PC, Reis VV. Early and late assessment of esophagocardioplasty in the surgical treatment of advanced recurrent megaesophagus. Arq Gastroenterol. 2016;53(4):235-9. https://doi.org/10.1590/S0004-28032016000400005 https://doi.org/10.1590/S0004-2803201600...
Oliveira et al.²⁰20. Oliveira GC, Rocha RLB, Coelho-Neto JS, Terciotti-Junior V, Lopes LR, Andreollo NA. Esophageal mucosal resection versus esophagectomy: a comparative study of surgical results in patients with advanced megaesophagus. Arq Bras Cir Dig. 2015;28(1):28-31. https://doi.org/10.1590/S0102-67202015000100008 https://doi.org/10.1590/S0102-6720201500...
Crema et al.⁸8. Crema E, Terra Júnior JA, Borges MA, Queiroz CAS, Soares LA, da Silva AA. Preservation of the vagus nerves in subtotal esophagectomy without thoracotomy. Acta Cir Bras. 2018;33(9):834-41. https://doi.org/10.1590/s0102-865020180090000012 https://doi.org/10.1590/s0102-8650201800...
Aquino et al.²2. Aquino JLB, Said MM, Pereira DAR, Machado FR, Ramos JPZ, Brandi Filho LA, et al. Análise comparativa da mucosectomia esofágica e da esofagectomia transmediastinal no tratamento do megaesôfago avançado: estudo comparativo em 229 pacientes. Anais do 32o Congresso Brasileiro de Cirurgia; 2017; Brasília. Brasília: CBC; 2017.
Felix et al.¹⁰10. Felix VN, Yogi I, Martins CEN, Padrão EMH, Silva AGM, Faria KVM. Maximizing results of esophagectomy for advanced achalasia. Available from: http://www.valterniltonfelix.com.br/pdf/medicina/profissionais/Artigo-14.pdf. Assessed: Jan. 25, 2016. http://www.valterniltonfelix.com.br/pdf/...
Panchanatheeswaran et al.²⁶26. Panchanatheeswaran K, Parshad R, Rohila J, Saraya A, Makharia GK, Sharma R. Laparoscopic Heller’s cardiomyotomy: a viable treatment option for sigmoid oesophagus. Interact Cardiovasc Thorac Surg. 2013;16(1):49-54. https://doi.org/10.1093/icvts/ivs427 https://doi.org/10.1093/icvts/ivs427...
Simic et al.³¹31. Simić AP, Skrobić OM, Velicković D, Ražnatović Z, Šaranović D, Šljukić V, et al. Minimally invasive surgery for benign esophageal disorders: first 200 cases. Eur Surg. 2015;47(1):25-34. https://doi.org/10.1007/s10353-015-0296-x https://doi.org/10.1007/s10353-015-0296-...
Molena et al.¹⁸18. Molena D, Mungo B, Stem M, Feinberg RL, Lidor AO. Outcomes of esophagectomy for esophageal achalasia in the United States. J Gastrointest Surg. 2014;18(2):310-7. https://doi.org/10.1007/s11605-013-2318-y https://doi.org/10.1007/s11605-013-2318-...
Costantini et al.⁷7. Costantini M, Salvador R, Capovilla G, Vallese L, Costantini A, Nicoletti L, et al. A thousand and one laparoscopic Heller myotomies for esophageal achalasia: a 25-year experience at a single tertiary center. J Gastrointest Surg. 2019;23(1):23-35. https://doi.org/10.1007/s11605-018-3956-x https://doi.org/10.1007/s11605-018-3956-...
Tassi et al.³³33. Tassi V, Lugaresi M, Mattioli B, Daddi N, Pilotti V, Ferruzzi L, et al. Quality of life after operation for end-stage achalasia: pull-down Heller-Dor versus esophagectomy. Ann Thorac Surg. 2022;113(1):271-8. https://doi.org/10.1016/j.athoracsur.2020.12.048 https://doi.org/10.1016/j.athoracsur.202...
	Domains:						Judgment
	D1: Bias due to confounding.							Critical
	D2: Bias due to selection of participants.							Critical
	D3: Bias in classification of interventions.							Serious
	D4: Bias due to deviations from intended interventions.							Serious
	D5: Bias due to missing data.							Moderate
	D6: Bias in measurement of outcomes.							Moderate
	D7: Bias in selection of the reported result.							Low

Groups	Morbidity/complications	Mortality
Cardiomyotomy	0.08	0.03
Major surgeries	0.49	0.05

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[1] Correspondence: Paulo Sérgio Chaib. E-mail: pschaib@gmail.com, paulo.sc1@puccampinas.edu.br