Mucosectomy and Endomuscular Pull-Through: Non-Conventional Surgical Approach to Achalasia

Aim: Esophageal achalasia is characterized by incomplete relaxation of the lower esophageal sphincter and absence of peristalsis along the esophageal body with a consequence dilatation of the organ. Transhiatal esophagectomy is a therapeuthic option for the treatment of end-stage achalasia that avoids the complications of a thoracotomy. This technique; however, is still linked to some degree of morbimortality especially due to pleuromediastinal complications. Esophageal mucosectomy and endomuscular pull-through could avoid these complications. This study aims to evaluate the short and long-term outcomes of esophageal mucosectomy and endomuscular pull-through in a series of patients with advanced megaesophagus.

Methods: We retrospectively studied 115 patients with end-stage achalasia who underwent esophageal mucosectomy and endomuscular pull-through. Digestive tract reconstruction was accomplished most times using the gastric pull-up into the muscular tunnel. Forty-two patients were followed for more than 10 years. Outcomes were evaluated in a short and long-term follow-up based on clinical, endoscopic and tomographic evaluation.

Results: A complete removal of the mucosa was observed in all 115 patients. Anastomotic leak or stenosis was present in 27%. Pleural effusion was noticed in 11% and pneumonia in 9%. Mortality was 1.7%. Long-term follow-up (over 10 years) was possible in 42 patients. Excellent and good clinical results were obtained in 83% of the patients.

Conclusion: Esophageal mucosectomy and endomuscular pull-through is a valuable procedure for the treatment of end-stage achalasia. It shows a low rate of complications and good outcomes at long-term follow-up.