Oesophagectomy in the management of end-stage achalasia – Case reports and a review of the literature

Achalasia is an oesophageal motility disorder characterised by aperistalsis and failure of relaxation of a hypertensive lower oesophageal sphincter. Treatment intent targets the sphincter, and either Heller’s myotomy or pneumatic dilatation successfully relieves dysphagia in the majority of cases. End-stage achalasia, typified by a massively dilated and tortuous oesophagus, may occur in patients previously treated but where further dilatation or myotomy fails to relieve dysphagia or prevent nutritional deterioration, and oesophagectomy may be the only option. We describe two patients with end-stage achalasia and nutritional failure despite exhaustive conventional therapy including pneumatic dilatation and surgical myotomy. Both patients were successfully managed with transhiatal oesophagectomy and cervical gastro-esophageal anastomosis, with excellent symptomatic control and improved quality of life. These cases are discussed and the literature reviewed.