The choice of conduit for esophageal reconstruction in benign disease requires consideration of patient specific characteristics and concerns for reflux esophagitis. Factors that contribute to this decision include previous operations on the stomach or colon, other diseases of the gastrointestinal tract, and reliable blood supply to these organs. A gastric conduit allows for a less complex operation with only one anastomosis, whereas colonic or jejunal interposition requires a much more complex operation. The debate still continues as to which reconstruction results in better physiologic gastrointestinal functioning, but in recent reports many prefer to use the stomach as a conduit if this is available. Effective medications to treat reflux disease undoubtedly had a role influencing this practice [11, 17, 18]. Colonic interposition outcomes have demonstrated possibly lower risks of chronic reflux, anastomotic stricture and dumping syndrome.

All approaches require proper exposure and careful dissection of the esophagus due to the changes secondary to the disease. First, due to the size of the megaesophagus, mediastinal organs are often displaced and the esophagus deviates into the right chest. This makes entry into the pleural cavity more common during esophageal mobilization, requiring tube thoracotomy if occurs. Mobilization of the distal esophagus and stomach can be complicated if a fundoplication had been previously performed. The wrap must be carefully undone with preservation of the stomach if a gastric conduit is planned. Mobilization of the proximal esophagus can also be challenging in these patients since the dilation of the esophagus will often extend all the way to the cervical esophagus at the thoracic inlet difficult, and extra attention must be given to the recurrent laryngeal nerves during the cervical dissection. In the thoracic esophagus, the hypertrophied esophagus muscle leads to a hyper-vascular esophagus with hypertrophied thoracic aortic branches. This factor exposes to the risk of bleeding and that it is why many surgeons prefer a trans-thoracic approach, which allows careful ligation of these vessels. Lastly, a large challenge in these patients is the adhesions secondary to previous interventions on the esophagus. A prior esophagomyotomy is often associated to adhesions between the esophagus and surrounding structures such as the aorta or lung. Thus dissection must be performed under direct vision and care taken to dissect the esophagus from these structures. This dissection may lead to entry into the esophageal lumen and spillage into the mediastinum, which should be treated with suture closure and copious irrigation of the mediastinum.

Esophageal resection can be simply performed en bloc, but since achalasia is a benign disease not requiring lymphadenectomy, a vagal-sparing esophagectomy can be considered. This procedure can be performed with the use of a vein stripper passed either through a gastrostomy in anterior cardia or the divided stomach up the esophagus to the divided proximal esophagus. The vein stripper, attached to the proximal esophagus is then used to pull the invaginated esophagus back through the stomach thus stripping the esophagus while leaving its mediastinal structures such as the vagal nerves. Vagal-sparing esophagectomy for patients with benign or pre-malignant disease not requiring lymphadenectomy, is associated with reduced post-vagotomy symptoms, less weight loss and fewer perioperative complications [25]. However these outcomes are reported for patients with otherwise normal esophageal function and minimal prior esophageal interventions. End-stage achalasia patients have a number of prior interventions and for the most part a non-functional esophagus, thus patients may already have disruption of the vagus nerve and if not the subsequent identification and preservation of the nerve during esophagectomy may not always be possible.