SCIENTIFIC REVIEW Esophagectomy for End-Stage Achalasia: Systematic Review and Meta-analysis Alberto Aiolfi 1 • Emanuele Asti 1 • Gianluca Bonitta 1 • Luigi Bonavina 1 Published online: 11 October 2017 Ó Socie ´te ´ Internationale de Chirurgie 2017 Abstract Background Indications for surgery and clinical outcomes of esophagectomy in the management of end-stage achalasia are not clearly defined. The aim of this systematic review and meta-analysis was to provide evidence-based information to help in the decision-making and in the choice of surgical technique. Methods An extensive literature search was conducted to identify all reports on esophagectomy for end-stage achalasia patients over the past three decades. MEDLINE, Embase and Cochrane databases were thoroughly con- sulted matching the terms ‘‘achalasia,’’ ‘‘end-stage achalasia,’’ ‘‘esophagectomy’’ and ‘‘esophageal resection’’ with ‘‘AND’’ and ‘‘OR.’’ Short- and long-term outcome data were extracted. Pooled prevalence of pneumonia, anasto- motic leakage and mortality were calculated using Freeman–Tukey double arcsine transformation and DerSimonian– Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I 2 -index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders. Results Eight papers published between 1989 and 2014 matched the inclusion criteria. In total, 1307 patients were included. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach. The stomach was used as an esophageal substitute in 95% of patients. Pooled prevalence of pneumonia, anastomotic leakage and mortality were 10% (95% CI 4–18%), 7% (95% CI 4–10%) and 2% (95% CI 1–3%), respectively. Conclusions Esophagectomy for end-stage achalasia is safe and effective. Based on the results of this study, esophagectomy should be performed without hesitation in patients who are fit for major surgery and present with disabling symptoms, poor quality of life and dolichomegaesophagus recalcitrant to multiple endoscopic dilatations and/or surgical myotomies. Introduction Achalasia is a rare disease, with an estimated annual incidence of 1 case per 100,000/year. It results from a dysfunction of the esophageal myenteric plexus that causes impaired lower esophageal sphincter (LES) relaxation and loss of peristalsis [1]. Dysphagia, regurgitation, weight loss, respiratory symptoms and aspiration pneumonia are common. The incidence of squamous cell carcinoma in achalasia is 312.4 cases per 100,000 patients/year [2]. Treatment of achalasia aims to reduce the pressure gradient across the LES and improve gravitational eso- phageal emptying in an effort to palliate symptoms and halt the natural history of the disease [3]. Pneumatic dilatation and surgical myotomy are the two most commonly used first-line treatment modalities [4, 5]. While some patients achieve excellent long-term symptom control with a single & Luigi Bonavina [email protected]1 Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Piazza Edmondo Malan, 1, 20097 San Donato Milanese, MI, Italy 123 World J Surg (2018) 42:1469–1476 DOI 10.1007/s00268-017-4298-7
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SCIENTIFIC REVIEW
Esophagectomy for End-Stage Achalasia: Systematic Reviewand Meta-analysis
Alberto Aiolfi1 • Emanuele Asti1 • Gianluca Bonitta1 • Luigi Bonavina1
Published online: 11 October 2017
� Societe Internationale de Chirurgie 2017
Abstract
Background Indications for surgery and clinical outcomes of esophagectomy in the management of end-stage
achalasia are not clearly defined. The aim of this systematic review and meta-analysis was to provide evidence-based
information to help in the decision-making and in the choice of surgical technique.
Methods An extensive literature search was conducted to identify all reports on esophagectomy for end-stage
achalasia patients over the past three decades. MEDLINE, Embase and Cochrane databases were thoroughly con-
sulted matching the terms ‘‘achalasia,’’ ‘‘end-stage achalasia,’’ ‘‘esophagectomy’’ and ‘‘esophageal resection’’ with
‘‘AND’’ and ‘‘OR.’’ Short- and long-term outcome data were extracted. Pooled prevalence of pneumonia, anasto-
motic leakage and mortality were calculated using Freeman–Tukey double arcsine transformation and DerSimonian–
Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and
Cochrane Q test. Meta-regression was used to address the effect of potential confounders.
Results Eight papers published between 1989 and 2014 matched the inclusion criteria. In total, 1307 patients were
included. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach. The
stomach was used as an esophageal substitute in 95% of patients. Pooled prevalence of pneumonia, anastomotic
leakage and mortality were 10% (95% CI 4–18%), 7% (95% CI 4–10%) and 2% (95% CI 1–3%), respectively.
Conclusions Esophagectomy for end-stage achalasia is safe and effective. Based on the results of this study,
esophagectomy should be performed without hesitation in patients who are fit for major surgery and present with
disabling symptoms, poor quality of life and dolichomegaesophagus recalcitrant to multiple endoscopic dilatations
and/or surgical myotomies.
Introduction
Achalasia is a rare disease, with an estimated annual
incidence of 1 case per 100,000/year. It results from a
dysfunction of the esophageal myenteric plexus that causes
impaired lower esophageal sphincter (LES) relaxation and
loss of peristalsis [1]. Dysphagia, regurgitation, weight
loss, respiratory symptoms and aspiration pneumonia are
common. The incidence of squamous cell carcinoma in
achalasia is 312.4 cases per 100,000 patients/year [2].
Treatment of achalasia aims to reduce the pressure
gradient across the LES and improve gravitational eso-
phageal emptying in an effort to palliate symptoms and halt
the natural history of the disease [3]. Pneumatic dilatation
and surgical myotomy are the two most commonly used
first-line treatment modalities [4, 5]. While some patients
achieve excellent long-term symptom control with a single