CORRESPONDENCE Surgical Therapy for End-Stage Achalasia To the Editor: Hsu and colleagues [1] presented a cohort of 8 patients with end-stage achalasia who had undergone unsuccessful esoph- agomyotomy in the distant past. All patients were treated with cardiectomy, distal esophagectomy, and replacement with a short-colon interposition using a left thoracoabdominal incision. The authors suggested that this approach relieves the esopha- geal obstruction with less morbidity than total esophagectomy through a right thoracotomy or a transhiatal approach. Neglected or inadequate surgical treatment of achalasia can result in the megaesophagus syndrome. Some esophageal sur- geons [2, 3] believe the best remedial operation for this condition is total esophagectomy, whereas others [4], including Hsu and associates, favor less extensive procedures. The authors demon- strated both subjectively (patient questionnaire) and objectively (barium swallow) that their approach can improve swallowing. However, the claim that their operation is less morbid does not seem to us to be supported by their data and the modern literature on this topic. To justify their approach, the authors made reference to a 2001 report by a group [2] from The University of Michigan reporting a complication rate of 30% in 93 patients with achalasia who underwent total esophagectomy. Hsu and co-workers they sug- gested that this degree of morbidity is excessive and can be limited by using their method. Although daunting, a 30% complication rate is within the accepted range of morbidity when all patients undergoing total esophagectomy are consid- ered [5–7] and is very similar to the complication rate reported by the authors for their operation. Most experienced esophageal surgeons would agree with Hiebert and Bredenberg [8] that “the most critical determinant of morbidity [in esophageal operations] is the surgeon’s proficiency based on a personal experience with the operation.” As a result, there is little consensus regarding many aspects of the surgical treatment of esophageal pathological conditions. We respect the desire of Hsu and associates to present an alternative approach to a difficult clinical problem but question whether their procedure really is simpler for the surgeon and less morbid for the patient. Joseph H. Gorman III, MD Robert C. Gorman, MD Emest F. Rosato, MD Department of Surgery Hospital of The University of Pennsylvania 3400 Spruce St, 6 Silverstein Philadelphia, PA 19104 e-mail: gormanj@uphs.upenn.edu References 1. Hsu H-S, Wang C-Y, Hsieh C-C, Huang M-H. Short-segment colon interposition for end-stage achalasia. Ann Thorac Surg 2003;76:1706 –10. 2. Devaney EJ, Iannettoni MD, Orringer MB, Marshall B. Esoph- agectomy for achalasia: patient selection and clinical experi- ence. Ann Thorac Surg 2001;72:854 –8. 3. Peters JH, Kauer WK, Crookes PF, Ireland AP, Bremner CG, DeMeester TR. Esophageal resection with colon interposition for end-stage achalasia. Arch Surg 1995;130:632–6. 4. Ximenes M. Chagas’ disease. In: Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr, eds. Esophageal surgery. New York: Churchill Livingstone, 1995:443–57. 5. Birkmeyer JD, Stukel TA, Andrea E, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349:2117–27. 6. Peters JH, Kronson JW, Katz M, DeMeester TR. Arterial anatomic considerations in colon interposition for esophageal replacement. Arch Surg 1995;130:858 –62. 7. Orringer MB, Marshall B, Iannettoni MD. Transhiatal esoph- agectomy for treatment of benign and malignant esophageal disease. World J Surg 2001;25:196 –203. 8. Hiebert CA, Bredenberg CE. In: Pearson FG, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr, eds. Esophageal surgery. New York: Churchill Livingstone, 1995:649. Reply To the Editor: We thank Dr Gorman and colleagues for their concerns regard- ing the morbidity experienced by the patients in our article [1] (9 patients with end-stage achalasia who had prior failure of esophagomyotomy). According to Gorman and coauthors, we suggested that our approach for patients with end-stage acha- lasia and a previous failed esophagomyotomy can relieve the esophageal obstruction with less morbidity than total esopha- gectomy through a right thoracotomy or a transhiatal approach [2, 3]. Actually, our conclusion was that limited distal esopha- gectomy with short-colon interposition through a left thoraco- abdominal approach is a safe and feasible alternative to nearly total esophagectomy in patients with achalasia in whom prior esophagomyotomy failed. We did not claim that the operation we performed was less morbid than total esophagectomy through a right thoracotomy or a transhiatal approach. The complications we encountered in the series included one wound infection and one prolonged intubation, which were minor, and one intestinal strangulation, which may not have been tech- nique related. Because of the small number of patients involved, we did not compare the morbidity with that in other reports. We understand that the procedure of short-colon interposi- tion through a left thoracoabdominal approach can require three anastomoses and pyloroplasty. The procedure itself would not be easy for the surgeon or for the patients. However, the advan- tages include less dissection of the intrathoracic esophagus and easy mobilization of the wrapped esophagogastric junction. There was no leakage noted in our patients. In their study, Devaney and co-workers [3] found that the exposed esophageal submucosa after prior esophagomyotomy typically became adherent to the adjacent aorta and left lung, thereby complicating transhiatal mobilization. They also mentioned that in their earlier experience, dense adhe- sions necessitated a thoracotomy to complete the mediastinal dissection in 6 of the patients. There are many issues that need to be addressed in the man- agement of this difficult medical problem. They include the ques- tions of how to relieve the esophageal obstruction, which substitute should be used, whether the esophagus should be totally removed in this benign disease and when it should be done, and which surgical procedure can provide better alimentary function postop- eratively. We also agree with Hiebert and Bredenberg [4] in their chapter on selection and placement of conduits in esophageal surgical procedures that “the most critical determinant of morbid- ity is the surgeon’s proficiency based on a personal experience with the operation.” In dealing with this benign but difficult disease, we are not suggesting that our procedure is simpler for the surgeon and less morbid for the patients than other procedures but merely that, although our experience is limited, we are satisfied with the results we have seen to date. Han-Shui Hsu, MD Min-Hsiung Huang, MD Division of Thoracic Surgery Department of Surgery Taipei Veterans General Hospital Number 201, Section 2 Shih-Pai Rd Taipei, Taiwan e-mail: hsuhs@vghtpe.gov.tw © 2005 by The Society of Thoracic Surgeons Ann Thorac Surg 2005;79:749 –56 • 0003-4975/05/$30.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.02.140 MISCELLANEOUS