2019 SCIENCELINE  
Journal of Life Science and Biomedicine  
J Life Sci Biomed, 9 (5): 138-143, 2019  
License: CC BY 4.0  
ISSN 2251-9939  
DOI: https://dx.doi.org/10.36380/scil.2019.jlsb22  
Esophagus extirpation in the surgical  
treatment of neglected stages of esophageal  
achalasia  
Feruz Gafurovich NAZIROV, Zaynitdin Mahamatovich NIZAMKHODJAYEV, Ruslan Efimovich LIGAY,  
Aleksey Olegovich TSOI, Doniyor Bakhtiyarovich SHAGAZATOV, Elnar Ildarovich NIGMATULLIN  
and Kudratbek Bahtiyarovich BABADJANOV.  
Republican Specialized Surgery Centre named after Academician V.Vakhidov, Tashkent city, Uzbekistan.  
Corresponding author’s Email: rscs.elnar@gmail.com  
ABSTRACT  
Original Article  
PII: S225199391900022-9  
Aim. The surgical treatment experience of patients with neglected stages of esophageal  
achalasia has been presented in the article. Methods. The esophagus extirpation with  
simultaneous gastroesophagoplasty due to esophageal achalasia of stage III-IV was  
performed in 28 patients. Results. The results of the research, identifies indications for  
surgical intervention, features of intra- and postoperative complications, immediate and  
long-term results of esophageal extirpation. Cardiodilation remains the main treatment  
method for patients with esophageal achalasia, but its efficiency is significantly reduced in  
patients with neglected stages. Conclusion. Esophagus extirpation in patients with  
neglected stages of achalasia is pathogenetically reasonable surgical intervention when  
there is severe esophagoectasia and S-shaped deformity of the esophagus and cardio-  
esophageal junction. Further control randomized trials and multicentric studies should be  
performed.  
Rec. 11 June 2019  
Rev. 23 September 2019  
Pub. 25 September 2019  
Keywords  
Achalasia,  
Neuromuscular diseases  
of the esophagus,  
Esophageal extirpation,  
gastroplasty.  
INTRODUCTION  
Esophageal achalasia is one of the most common neuromuscular diseases of the esophagus at which the  
dystrophy of the Auerbach’s plexus occurs. As a result, there is a disorder of the reflex of the cardia opening in  
response to a sip, the peristaltic activity of the esophagus is inhibited which leads to the development of severe  
esophagoectasia [1-4].  
The etiopathogenesis of the disease still remains unclear. All treatment options are symptomatic and  
aimed at eliminating the main symptom - dysphagia. The main method of treatment is cardiodilation which is  
effective at any stages of the disease. However, in neglected cases, as well as in the recurrence of dysphagia, the  
effect of dilation is much less and surgical treatment is often necessary. There are more than 60 variants of  
surgical interventions for achalasia, most of which are numerous modifications of the Geller’s operation. They  
are aimed to an extra-mucosal dissection of the distal esophagus and the stomach cardia muscles for reducing  
the gradient of the esophagogastric pressure, which facilitates the passage of the cardia [4-6]. However, in  
patients with achalasia the complete absence of the cardia opening in response to the sip and the complete  
absence of peristaltic activity of the esophagus wall, come to the fore. Therefore, in stage IV of the disease a  
good effect from cardioplastic operations cannot be expected.  
The esophagus extirpation remains one of the most complicated operations in thoraco-abdominal surgery  
which is characterized by trauma, duration, high risk of intraoperative and postoperative complications. In  
most cases it is performed at esophageal cancer. The main advantage of esophagus extirpation is a complete  
removal of the pathologically changed organ – the esophagus. There are isolated reports in the world literature  
on the experience of using the extirpation of the esophagus in patients with achalasia of the cardia, which can  
be considered the only radical method of surgical treatment of this category of patients [1-4, 7].  
Citation: Nazirov FG, Nizamkhodjayev ZM, Ligay RE, Tsoi AO, Shagazatov DB, Nigmatullin EE and Babadjanov KB. Esophagus extirpation in the surgical  
treatment of neglected stages of esophageal achalasia. J Life Sci Biomed, 2019; 9(5): 138-143; www.jlsb.science-line.com  
138  
This study aimed to investigate the esophagus extirpation results in the surgical treatment of neglected  
stages of esophageal achalasia.  
MATERIALS AND METHODS  
Ethical approval  
The review board and ethics committee of Republican Specialized Surgery Centre named after  
Academician V.Vakhidov approved the study protocol and informed consents were taken from all the  
participants.  
Total of 28 esophagus extirpations due to the neglected stages of achalasia were performed at the  
Department of Esophagus and Stomach Surgery of the Republican Specialized Scientific and Practical Medical  
Center of Surgery from 1998 to 2018. There were 18 males (64.2%) and 10 females (35.8%) participated in the  
study. The age of patients ranged from 11 to 62 years. Achalasia of stage III was in 4 patients (14.3%) and stage IV  
in 24 patients (85.7%). When collecting anamnestic data it was determined that 2 patients (7.1%) had previously  
undergone esophagogicardiomy, and 1 patient (3.6%) had previously undergone esophago-cardiomyotomy. The  
rest of patients were performed repeated courses of cardiodilation. The disease duration in all patients was  
more than 5 years.  
All patients were performed a comprehensive examination which included endoscopic, radiopaque  
investigations, as well as Modern methods of radiation diagnostics (MSCT). Characteristic features along with  
the clinical presentation were evident esophagoectasia, the absence of peristaltic activity of the esophagus  
muscular wall, S-shape deformity of esophagus and cardia. The X-ray pattern of patients with neglected stages  
of achalasia stage IV is presented in Figure 1.  
Figure 1. X-ray pattern of the esophagus (achalasia of stage IV)  
Modern methods of radiation diagnostics (MSCT) allow not only to make a diagnosis, but also to determine  
the features of topographic-anatomical ratio of the esophagus to the rest of the structures of the mediastinum  
and pleural cavities (Figure 2). This is important when mobilizing the esophagus from the mediastinum through  
abdomino-cervical approach which is limited for visualization.  
Citation: Nazirov FG, Nizamkhodjayev ZM, Ligay RE, Tsoi AO, Shagazatov DB, Nigmatullin EE and Babadjanov KB. Esophagus extirpation in the surgical  
treatment of neglected stages of esophageal achalasia. J Life Sci Biomed, 2019; 9(5): 138-143; www.jlsb.science-line.com  
139  
Figure 2. MSCT pattern of the esophagus (achalasia of stage IV)  
RESULTS  
The main methods of patients treatment with achalasia are various cardiodilation options (pneumatic,  
hydroballoon). However, in patients with neglected III-IV stages when there is S-shaped deformity, both of the  
esophagus and the stomach cardia, the possibilities of dilatation are sharply limited and the restoration of food  
patency is short. Such patients have to be performed surgical treatment. Indications for the esophagus  
extirpation in our patients were:  
Dilatation inefficiency, i.e. directly unsatisfactory result when after repeated (5-7) sessions patients did  
not have a clinical effect – in 8 cases (28.6%);  
The impossibility of holding the dilator in the stomach which was evaluated on the basis of a  
comprehensive examination and was confirmed when trying to hold the dilator, when the risk of the esophagus  
injury exceeded the expected clinical effect – in 17 cases (60.7%);  
Stenotic reflux esophagitis of the lower third of the thoracic esophagus against the background of  
previously performed esophagocardiomyotomy – in 3 cases (10.7%).  
There are 5 main factors in solving the issue of using esophageal extirpation in patients with neglected  
stages of achalasia:  
1. Simultaneous performance of esophagoplasty. In all 28 cases the resection and recovery stage  
(esophagoplasty) were performed in one stage.  
2. The choice of surgical approach. Abdomino-cervical approach was used in 27 patients (96.4%) and  
thoraco-abdomino-cervical approach was performed in 1 case (3.6%) because of the presence of concomitant  
pathology (echinococcosis of the middle lobe of the right lung) a simultaneous echinococcectomy from the lung  
was performed. The choice of the surgical approach nature was based on the fact that achalasia is a benign  
disease and does not require extensive lymphadenectomy, as the esophageal cancer, and therefore it is not  
advisable to use traumatic thoracic approach.  
3. Volume of the esophagus resection (extirpation or resection). In patients with neglected stages of  
achalasia, esophagoectasia of all parts of the esophagus is noted due to dystrophy of the Auerbach’s plexus. In  
the presence of indications for radical surgery it is necessary to remove almost the entire esophagus. Therefore,  
in all cases we performed the extirpation of the esophagus while leaving only a part of the cervical esophagus  
(3-4 cm) which was enough to form an anastomosis on the neck.  
4. Method of esophagoplasty. When choosing the method of esophagoplasty, we preferred the use of an  
isoperistaltic gastric tube from the greater curvature of the stomach which was used in 24 patients. Only in 4  
patients we used the left half of the colon to create a transplant due to the impossibility of gastroplasty.  
5. Level of esophageal anastomosis application (intrapleural or extracavitary cervical). The solution of this  
issue is debatable only in patients with esophageal cancer. In all cases a cervical extracavitary esophageal  
anastomosis was formed in patients with achalasia.  
The stages of the esophagus extirpation with gastroplasty have been shown in figure 3.  
Citation: Nazirov FG, Nizamkhodjayev ZM, Ligay RE, Tsoi AO, Shagazatov DB, Nigmatullin EE and Babadjanov KB. Esophagus extirpation in the surgical  
treatment of neglected stages of esophageal achalasia. J Life Sci Biomed, 2019; 9(5): 138-143; www.jlsb.science-line.com  
140  
A
B
C
Figure 3. The stages of the esophagus extirpation with gastroplasty. A= Mobilization of the esophagus after  
diaphragmotomy. B= The extracted esophagus with mobilized stomach. C= The formed gastrotransplant  
A
B
Figure 4. The extracted macro-preparation. A= The mobilized esophagus. B= The extracted macro-preparation.  
Citation: Nazirov FG, Nizamkhodjayev ZM, Ligay RE, Tsoi AO, Shagazatov DB, Nigmatullin EE and Babadjanov KB. Esophagus extirpation in the surgical  
treatment of neglected stages of esophageal achalasia. J Life Sci Biomed, 2019; 9(5): 138-143; www.jlsb.science-line.com  
141  
Complications of the esophagus extirpation in patients with neglected stages of achalasia are divided into  
intraoperative, immediate and late postoperative complications. The difficulty of the esophagus extirpation in  
patients with neglected stages of achalasia is in the difficulty and danger of the esophagus mobilization through  
the abdomino-cervical approach which are caused by severe esophagectasia and periesophagitis. In this regard,  
we observed the following intraoperative complications: bleeding from the mediastinum in 5 (17.8%) which was  
stopped intraoperatively by a mediastinal plugging; injury of the mediastinal pleura in 14 (50%) which required  
additional drainage of the pleural cavities; injury of the left recurrent nerve in 4 (6.3%) which caused a  
temporary loss of voice and a disorder of the swallowing act and which was normalized during the first 6  
months after the operation against the background of therapy in the ENT specialists.  
The following complications were observed in the immediate postoperative period: bronchopulmonary  
complications in 5 patients (17.8%): pneumonia in 2 patients, exudative pleurisy in 3 patients and specific  
complications in 1 patient (3.6%) had the esophagogastro-anastomosis failure.  
All complications were stopped by conservative measures. No lethal outcomes were observed. All 28  
patients were examined in the long-term period, in terms from 6 months to 20 years. Only in 2 cases (7.2%)  
cicatricial narrowing of esophagogastrostomy was diagnosed which required repeated bougienage and  
dilatation courses with a good clinical effect.  
CONCLUSION  
The main treatment method for the patients with achalasia remains cardiodilation which belongs to the  
minimally invasive methods and allows ensuring adequate restoration of food patency. However, in patients  
with neglected stages its efficiency is significantly reduced, and the frequency of recurrent dysphagia is  
increased. In patients with neglected stages of achalasia when the peristaltic activity of the esophagus is  
completely lost severe esophagoectasia is developed, as well as S-shaped deformation of the esophagus and the  
cardia itself. The operation of choice for these patients is the esophagus extirpation with simultaneous  
gastroesophagoplasty and the formation of extracavitary esophagogastroanastomosis in the neck. Compliance  
with all principles of gastroesophagoplasty will minimize the risk of dangerous intraoperative and  
postoperative complications. Further control randomized trials and multicentric studies should be performed.  
Though the represented study is a singe center results and control randomized trials and multicentric studies  
should be performed.  
DECLARATIONS  
Acknowledgements  
This work was supported by “Republican Specialized Surgery Centre named after Academician  
V.Vakhidov”, Tashkent. Uzbekistan.  
Authors’ Contributions  
All authors contributed equally to this work.  
Competing interests  
The authors declare that they have no competing interests.  
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