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Safety, Efficacy, and Patient Satisfaction Following Esophagectomy for Esophageal Neuromotor Disease: A Single Institution Experience
Samantha L. Savitch, Jonathan E. Williams, Andrew C. Chang, Rishindra Reddy, Jules Lin, Mark B. Orringer, Kiran H. Lagisetty
Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, United States
Background: Esophagectomy remains the mainstay of treatment for patients with end-stage achalasia and other esophageal neuromotor diseases, yet there are limited data on outcomes after esophagectomy in this population. Prior studies have relied on large, retrospective datasets that lack granularity or follow-up data to elucidate long-term outcomes and quality of life. We hypothesized that patients will have good long-term outcomes and improved function after esophagectomy for end-stage esophageal neuromotor disease. Methods: We retrospectively queried a prospectively collected database of all esophagectomies performed at a single, high-volume institution between 1975 and 2023 for non-cancer patients with a diagnosis of end-stage esophageal neuromotor disease. Operative characteristics, perioperative and functional outcomes, and mortality were evaluated. Patients with and without a prior esophageal operation were compared using chi-square for categorical variables, linear regression for continuous variables, and a log-rank test for survival data, with a p-value less than 0.05 considered significant. Results: A total of 237 patients were included for analysis, three of whom had a concomitant recurrent hiatal hernia. The majority of patients were female (135, 57.0%), Caucasian (196, 82.7%), and non-smokers (128, 83.7%). Mean age was 52.4 years (standard deviation [SD] 16.2 years). 185 (78.1%) patients had a diagnosis of achalasia. 72.2% (171/273) of patients had a prior esophageal operation, of which 129 (75.4%) were a myotomy. The majority of esophagectomies performed were transhiatal and a gastric conduit was successfully used in 228 patients (96.2%). Rate of anastomotic leak was 8.4% (20/237), and 6 of those patients (30.0%) required reoperation prior to discharge. Median length of stay (LOS) was 10 days (IQR 7-12). There was one in-hospital death; there were no other deaths within 30 days of surgery. There was no significant difference in hospital LOS, anastomotic leak, intraoperative blood loss, operative approach, ICU admissions, or overall survival between patients who had and had not had a prior esophageal operation. Postoperative functional symptoms (dysphagia, cramping, diarrhea, regurgitation, nausea) were reported in 69.9% of patients at first follow-up (mean days post-op 82.7). The percentage of patients with persistent symptoms did not significantly change at subsequent follow-up visits, and follow-up data was available beyond one year for 125/273 patients (45.8%). 96 (40.5%) patients required at least one postoperative dilation for symptom management, and only two patients required anastomotic revision over the mean follow-up period of 2033 days. When asked at follow-up, the majority of patients stated that they felt better (93.9%) and would undergo esophagectomy again (96.5%). Conclusion: In this single institution experience, esophagectomy for esophageal neuromotor disease is safe and feasible with a gastric conduit, regardless of prior esophageal operations. Despite persistent postoperative functional symptoms, patients who undergo esophagectomy for neuromotor disease have high satisfaction following the procedure. Based on these findings, esophagectomy should be considered for patients with end-stage esophageal dysfunction for definitive management of symptoms.
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