Esophagectomy for Achalasia
Esophagectomy is NOT a first-line treatment for achalasia and should only be considered as a last-resort salvage procedure after failure of primary therapies (pneumatic dilation, laparoscopic Heller myotomy, or POEM) or in highly selected cases of end-stage disease with sigmoid esophagus. 1, 2, 3
Primary Treatment Options for Achalasia
The established first-line treatments for achalasia include:
Pneumatic balloon dilatation (PD): Effective in 90% of patients in the first year, with long-term success rates of 97% at 5 years and 93% at 10 years with repeat dilatations 1
Laparoscopic Heller myotomy (LHM) with fundoplication: Considered the most effective first-line surgical treatment, particularly when combined with Dor fundoplication to prevent gastroesophageal reflux 1, 4
Per-oral endoscopic myotomy (POEM): Preferred primary therapy for type III (spastic) achalasia due to ability to perform longer myotomy, and comparable to LHM for other achalasia subtypes 5, 1
When Esophagectomy May Be Considered
Esophagectomy has extremely limited indications in achalasia:
Specific Scenarios for Consideration:
Failed prior myotomy: Patients with recurrent symptoms after previous esophagomyotomy who cannot be managed with repeat interventions 6
Megaesophagus/sigmoid esophagus: Patients with massive esophageal dilation (≥8 cm diameter) or sigmoid configuration, though even these patients should first attempt myotomy 4, 6, 3
End-stage disease after multiple failed interventions: Only after exhausting all other therapeutic options 2, 3
Critical Caveat:
Even in patients with massively dilated esophagus (>7 cm), pneumatic balloon dilation can be successfully performed as first-line treatment with good symptomatic improvement, making esophagectomy unnecessary in most cases 7
Why Esophagectomy Is Reserved as Last Resort
The rationale for avoiding esophagectomy unless absolutely necessary:
LHM with Dor fundoplication is effective even in sigmoid achalasia, though outcomes are not as favorable as in non-sigmoid cases 4
Multiple endoscopic treatments make subsequent myotomy more difficult but do not preclude it 4
Esophagectomy carries significant operative risk compared to myotomy procedures 6, 3
International guidelines recommend laparoscopic or endoscopic approaches initially in most patients, even those with end-stage disease 3
Algorithmic Approach to Achalasia Treatment
Step 1: Initial Treatment Selection
- Type I or II achalasia: PD or LHM with fundoplication 1
- Type III achalasia: POEM as preferred option 5, 1
- Elderly or high-risk surgical patients: Consider botulinum toxin injection 4
Step 2: If Initial Treatment Fails
- After failed PD: Repeat dilation or proceed to LHM 1
- After failed myotomy: Consider POEM if prior LHM, or repeat myotomy 4
- Persistent symptoms with massive dilation: Still attempt repeat dilation or alternative myotomy approach 7
Step 3: Esophagectomy Consideration
Only after documented failure of:
- Multiple pneumatic dilations 6
- At least one myotomy procedure (laparoscopic or endoscopic) 2, 3
- In setting of megaesophagus (≥8 cm) or severe sigmoid configuration with intractable symptoms 6, 3
Important Clinical Pitfalls
Do not proceed directly to esophagectomy even in patients with radiographically impressive esophageal dilation, as less invasive treatments remain effective 7
Avoid multiple failed endoscopic treatments before definitive myotomy, as this worsens surgical outcomes 4
Consider that up to 20% of achalasia patients progress to end-stage disease, but this still does not make esophagectomy first-line 3
Recognize that esophagectomy for achalasia should be viewed similarly to rescue esophagectomy for other conditions—reserved for extensive failure of standard approaches 5