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Dysphagia complicating hiatal hernia repair
J
THoRAc CARDIOVASC SURG
88:922-928, 1984
Dysphagia complicating hiatal hernia repair Dysphagia may be a continuing or added problem after operations for the control of reflux. In a series of 208 patients treated surgically for recurrent hiatal hernia, 34 (16.3%) presented with dominant dysphagia either caused by or aggravated by the operation. They were evaluated by history, radiology, manometry, and endoscopy. The causes of dysphagia were diagnosed in all patients: reflux stricture in nine patients, tight or long Nissen wrap in 15, muscle injury in three, inappropriate myotomy with reflux in three, myotomy with overcompetent repair in two, and early Nissen innmusception in two patients. Surgical correction was by total fundop6cation gastroplasty in 32 patients, Nissen repair in one, and colon interposition in one. In four patients the myotomy was closed. Complete follow-up averages 5.4 years. There bas been one anatomic recurrence, 28 patients are asymptomatic, and five are much improved but have minor persistent dysphagia. Only by complete invesigation can the cause of dysphagia be recognized and treated.
R. D. Henderson, M.B., F.R.C.S., Toronto, Ontario, Canada
USPhagia is associated with a variety of esophageal disorders, both motor and mechanical. When severe dysphagia is the dominant symptom after surgical hiatal hernia repair, it can be a major diagnostic and therapeutic problem. In the present study, 34 patients were selected for evaluation from a series of 208 patients with recurrent hiatal hernias requiring surgical revision. These patients were analyzed because of having severe dysphagia as their dominant symptom. Investigation was aimed at determining the accuracy of investigative parameters, the cause of dysphagia, and the effectiveness of surgical management. In this paper, dysphagia is the symptom recognized by the patient as being associated with esophageal obstruction by food. Severe dysphagia refers to the occurrence of food obstruction every day and with most meals. Patients and methods
Thirty-four patients have been fully investigated and treated surgically for severe dysphagia aggravated by, produced, or occurring as a late complication of hiatal hernia repair. Each patient was investigated by history, radiology, manometry with pH studies, acid perfusion, and endoscopy prior to surgical management. At the time of operation, the previous hernia repair was carefullv mobilized and inspected to determine further
From Women's College Hospital, Toronto, Ontario, Canada. Read at the Sixty-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N. Y., May 7-9, 1984.
922
its original design and the anatomic problems associated with dysphagia. History was obtained with a prepared format. All patients had one or more previous hernia repairs, and the preoperative symptoms of heartburn, reflux, nausea, vomiting, and dysphagia were demonstrated for each operation, as well as the symptoms at the time of presentation. Radiologic studies, conducted by one group of radiologists, included liquid barium and, when the diagnosis was in doubt, the addition of a barium sandwich to localize the site of obstruction. Manometric studies' were performed in conjunction with pH reflux (common cavity test)' and acid perfusion (Bernstein test).' Three polyethylene catheters were used for infusion manometry (inner diameter 1.19 mm), and water flow was maintained at 6.8 ml per tube per minute with a modified direct-drive Harvard syringe pump. A Beckman pH monitor and electrode were used for pH measurement. Esophagogastroduodenoscopy with a fiberoptic scope was performed in each patient before the operation. All surgical exposures were obtained by a left thoracoabdominal incision. After the diaphragm was divided circumferentially, the lower esophagus and gastric fundus were fully mobilized under direct vision. Thirty-three patients had a total fundoplication gastroplasty (TFG)4 and one a standard Nissen repair.' In five a previous esophageal myotomy was closed (including the standard Nissen patient), and one patient had resection of a traumatic diverticulum. The technique of TFG for recurrent hiatal hernia
Volume 88 Number 6 December, 1984
Fig. 1. Thoracoabdominal total fundoplication gastroplasty. A thoracoabdominal incision is made. Four to five short gastrics aredivided. Vagal nerves andvagal branch to liver are preserved. A 5 em gastroplasty tube is cut over a No. 60 Fr. bougie. LGA, Left gastric artery. repair has been previously described." With TFG the gastroplasty tube is cut from the lesser curvature of the stomach and calibrated over a No. 60 Fr. bougie. The gastroplasty is closed with 2-0 chromic sutures with 3-0 silkinvagination (Fig. 1). The fundus is passedclockwise posterior to the gastroplasty tube and positioned for suture fixation, The first step of fundoplication is to attach the fundus to the distal 1.5 em of the esophagus and to the full thickness of the suture line in the gastroplasty tube with 2-0 silk mattress sutures. This creates an intra-abdominal segment 6.5 em long. Completion fundoplication was reduced to 1 em in length and sutured with three 2-0 silk mattress sutures (Fig. 2). In patients with a previous gastrectomy or myotomy, the completion fundoplication was reduced to less than 0.5 em in length while the same intra-abdominal segmental length was maintained. In patients with a previous myotomy, the muscle edges of the myotomy were dissected free of mucosa. Although technically difficult, this was accomplished in each case without entering the esophageal lumen. The muscle was closed with continuous 2-0 catgut and interrupted 3-0 silk sutures (Fig. 3). In the one patient with a previous operative muscle injury, an epiphrenic diverticulum was excised. The lumen was closed to the muscle layer with 2-0 catgut and 3-0 silk. Results
The purpose of this study was threefold: to determine the diagnostic criteria necessary in evaluating major
Dysphagia complicating hiatal hernia repair 9 2 3
Fig. 2. The new fundus is sutured to the gastroplasty suture line anddistal 1.5 cmofesophagus. Completion fundoplication is reduced to 1 em length. T.F., Total fundoplication.
Fig. 3. Repair of esophageal myotomy. In patients with an esophageal myotomy the muscle margins must be mobilized and approximated with care. In the present study closure was with 2-0chromic catgut and continuous silk sutures. dysphagia complicating hiatal hernia repair, to determine the cause of dysphagia, and to establish effective methods of management. There were 12 male and 22 female patients. The age range was 17 to 69 years (average 46.3 years). The 34 patients had had seven different types of operation: Belsey hernia repair,' five patients; partial fundoplication gastroplasty (PFG),8 four patients; Nissen repair, 16 patients; TFG, three patients; extended myotomy with Belsey repair, two patients; myotomy with Nissen repair, three patients; and esophagogastrostomy, one patient. In three of the five patients with
The Journal of Thoracic and Cardiovascular Surgery
9 2 4 Henderson
Table I. Presenting symptoms Heartburn Total fundoplication Partial fundoplication Myotomy Esophagogastroscopy
8 7 3 I
19 9 5 1
Reflux
No eructation
Nausea
Vomiting
10 6 5 1
12 I 2 0
12 5 3 1
6 3 2 0
Legend: All patients had dysphagia. Reflux and heartburn were more common in those with partial fundoplication procedures. All esophageal pain was considered to be heartburn. as pain from food obstruction and reflux could not be clearly distinguished.
Table II. Radiologic investigation Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Normal
Recurrent reflux
Recurrent stricture
Diverticulum
Retention
16 4 1 0
2 1 I 0
0 4 1 1
I 0 0 0
0 0 2 0
Legend: Liquid barium studies did not always demonstrate obstruction. In those with normal studies, solids were added and obstruction always was demonstrated.
Table
m. Endoscopic evaluation
Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Competent junction
Incompetent junction
Ulcerative esophagitis
18 0 3 0
I 9 2 1
1 0 0 0
Stricture
Retention
0 4 1
0 0 3 0
I
Legend: With total fundoplication 94.7% had a competent junction with no evidence of reflux. In the partial fundoplication group, l()()% had an incompetent junction.
myotomy, the high-pressure zone had deliberately not been incised. The results of the investigation will be reported in four major categories defined by the type of fundoplication, the presence of a myotomy, and the use of an esophagogastrostomy. These categories are as follows: (1) total fundoplication (Nissen: TFG), 19 patients; (2) partial fundoplication (Belsey: PFG), nine patients; (3) myotomy of esophagus, five patients; and (4) esophagogastroscopy, one patient. The preoperative diagnosis had been reflux in 29, diffuse esophageal spasm in four, and achalasia in one. After investigation in the five with myotomy, the original diagnosis proved to be inaccurate. In total, these patients had had 59 previous operations at the time of presentation, including five patients with previous gastric operations. Before the most recent operation all had symptoms of esophageal pain and 19 had dysphagia. After the most recent operation, dysphagia had become the dominant symptom and necessitated further investigation and surgical management. In addition to gastroesophageal dysphagia, six had cricopharyngeal dysphagia, 19 described esophageal pain related to food intake, 21
described reflux, 14 aspiration, 15 inability to eructate, 10 hiccoughs, eight water brash, 23 nausea, 12 vomiting, and eight inability to vomit. These symptoms are correlated to the operative design (Table I). Radiologic studies with liquid barium disclosed abnormalities in only 13 patients. Ten had a recurrent hiatal hernia or reflux and six of these had a radiologic stricture. One had a traumatic diverticulum. Obstruction with solid foods could be demonstrated in all, ranging from delayed esophageal emptying to total obstruction and food retention or regurgitation (Table
11).
The esophagogastric junction was assessed endoscopically to determine competence or incompetence, and the esophageal mucosa was assessed for ulcerative esophagitis or stricture. Esophageal mucus and food retention was also noted (Table III). Manometric and pH studies demonstrated anatomic recurrence and reflux in 10 and too long a wrap with an incorporated lower esophagus in three. In the five with a previous myotomy, it was possible to exclude diffuse esophageal spasm and achalasia. In one patient, previously believed to have achalasia, a diagnosis of scleroderma with reflux was made (Table IV).
Volume 88 Number 6 December, 1984
925
Dysphagia complicating hiatal hernia repair
Table IV. Manometric evaluation No. Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Recurrent hiatal hernia or reflux
Incorporated esophagus
Incorrect diagnosis
4
3 0 0 0
0 0
19 9 5 1
5 0 I
5 0
Legend: A manometric diagnosis was made in 18 of 34 patients (53%). In those with a previous myotomy it was possible to exclude achalasia and diffuse esophageal spasm and to diagnose scleroderma in one patient.
Table V. Cause of dysphagia (combined data)
Total fundoplication Partial fundoplication Myotomy, Nissen Myotomy, Belsey Esophagogastrostomy
Traumatic diverticulum
Nonpeptic stricture
1
1 1
o
o o o
o
o o
Legend: With total fundoplication a tight or long fundoplication was the most common problem. Intussusception recurrence, although rare, is specific to total fundoplication. The nonpeptic strictures are related to diaphragmatic tightness and suture reaction. With the partial fundoplications, reflux with or without stricture produced dysphagia. In the myotomy group, reflux, an overcompetent repair, or an intact high-pressure zone was the problem. In the patient with an esophagogastrostomy, a stricture developed at the anastomotic site. Intuss., Intussusception. Rec., Recurrence. Cont., Continued.
At the time of operation, the previous repair was carefully dissected to determine the anatomic defect; however, a clinical diagnosis, based on the described investigation, had been determined before operation. In all patients with a Belsey repair or PFG, a diagnosis was established preoperatively based on the preoperative investigation. This was also the case in patients with a myotomy. However, 19 patients with a prior Nissen repair or TFG were more of a diagnostic challenge. In 12 the only abnormal finding was the radiologicdemonstration of obstruction to solids. In this group the obstruction was considered to be related to the fundoplication, and this assumption was confirmed at operation. These patients all had the immediate onset of dysphagia or worsening of preoperative dysphagia after the operation. With the TFG procedures, too long or too tight a fundoplication was the most common problem. In those with PFG, continued reflux with or without stricture was the most common cause of dysphagia (Table V). Surgical results I have obtained clinical follow-up in all patients, radiologic studies in 30 (88.2%), and manometry with pH reflux testing in 21 (61.7%). Follow-up ranges from 2 to 8.5 years and averages 5.4 years. None has reflux or anatomic recurrence. Thirty patients (88.2%) are asymptomatic and eating normally. Three patients (8.8%) have minor residual
symptoms, one with scleroderma has a slowly.resolving stricture, one has gastritis, and one has nonspecific complaints, but no dysphagia. One patient (3%) with a repaired myotomy intially did well, but the myotomy repair failed and she required colon interposition. Discussion In the introduction I noted that this investigation had three main purposes: (1) to determine the accuracy of the investigative parameters, (2) to evaluate the causes of dysphagia with each of the operations used, and (3) to evaluate the effectiveness of surgical management. The investigative parameters are history, radiology, manometry, and endoscopy. History was of value in determining when dysphagia occurred in relation to the various operation. Onset of dysphagia immediately after the operation is a strong indication that the problem is related to the operative technique rather than anatomic breakdown. The type of previous operation is also part of the history. In the present study 30% of the 208 patients with recurrent hernias had had a previous TFG procedure, and 19 of the 34 (56%) with dysphagia had had a TFG operation. This strongly suggests that dysphagic problems are more common with TFG. Radiology was effective in demonstrating anatomic recurrence with breakdown of the fundoplication, but it did not demonstrate an intussusception recurrence. Strictures were all detected radiologically. In the five with a myotomy, either reflux or major retention was
The Journal 01 Thoracic and Card iovascular Surgery
9 2 6 Henderson
~ :
!:
!!
i
ii
cm w a t e r M J !
~
~g
10
o
: G ! 1
i
i
~
!:
i HPZ !
P
0
P
o
P
I : : :
:
i Lowe'r Esophagus
i i i
'L1.1J
seconds
Fig. 4. Nissen repair-too long a fundoplication. A manometric trace is illustrated. Pressure is shown on the left side and the speed of paper motion indicated below. Vertical lines indicate proximal 1 em moves of the catheters. The high-pressure zone (HPZ) is shown as a zone of elevated pressure. Distal esophageal pressure is elevated because of the surrounding Nissen fundoplication. Proximal esophageal pressure is normal. G. Stomach. P, Peristalsis. D, Disordered motor waves.
3-4cm Fundopllcallon
Intraabdominal Segment
= Fundoplication Length
Fig. 5. With a standard Nissen using gastroesophagogastric sutures, the intra-abdominal segment and fundoplication length are equal.
demonstrated. The addition of solids was very important, and in 12 patients (35%) obstruction with solid food was the only demonstrable abnormality. In the past, manometry has demonstrated incompetence of the high-pressure zone in patients with a hiatal hernia, and Code's analysis can be used to make a diagnosis in 69% of patients.' In the present study, the fact that preoperative manometry was not usually available for comparison decreased the diagnostic accuracy in evaluating hernia recurrence. In three patients, incorporation of the lower esophagus was demonstrated (Fig. 4), indicating increased length of the fundoplication. Manometry was of particular value in the five patients with previous myotomies in whom an incorrect diagnosis of diffuse esophageal spasm or achalasia had been made.
Endoscopic investigation showed a high incidence of high-pressure zone incompetence in the group with a PFG and a competent junction in most patients with a TFG. Ulceration, stricture, food retention, and a diverticulum were also noted. Each investigative parameter was necessary , and a diagnosis, based on these studies, was made in all but 12 patients with a TFG. In this group, obstruction had been demonstrated radiologically with solids. All of these patients reported severe dysphagia immediately after the operation. In the 12, a clinical diagnosis of too tight or too long a fundoplication was made based on history, normal radiologic fmdings with liquid barium, and radiologic evidence of obstruction with solid food. Normal manometric and endoscopic results were considered to be supporting data.
Volume 88 Number 6 December, 1984
The intraoperative findings confirmed the preoperative evaluation in 32 patients (Table V). In two patients (non-peptic stricture group) the added fmding of suture reaction and a tight crural repair was recognized intraoperatively. In the two major groups the most common cause of postoperative major dysphagia was reflux with PFG and a tight or long wrap with TFG. The increased length of wrap has been shown to produce overcompetence?: 10 and is probably the most common error made in patients with a TFG procedure. For a standard Nissen fundoplication, most surgeons use a gastroesophagogastric suturing technique, which creates an intra-abdominal segment (Fig. 5) equal to the length of the completion fundoplication. With the TFG, the intra-abdominal segment is sutured separately and the completion fundoplication is tailored to a 1 em length. In the development of the TFG, the length of the completion fundoplication is the most important factor in producing overcompetence and dysphagia. Reducing wrap length to I em has almost eliminated dysphagia as a complication of TFG.9,10 In the surgical management of 33 of the 34 patients, dysphagia has been corrected by full mobilization and TFG. The only major residual problem in long-term follow-up was disruption of the myotomy repair in one patient. Considering the number and complexity of previous operations, this is a very conservative approach to surgical management. The results justify the surgical approach as an alternate to resection and interposition. REFERENCES
2
3
4 . 5
6
7
Henderson RD: Esophageal Manometry in Clinical Investigation, New York, 1983, Praeger Publishers Butterfield 00, Struthers JE Jr, Showalter JP: A test of gastroesophageal sphincter incompetence. The common cavity test. Am J Dig Dis 17:415, 1972 Bernstein LM, Fruin RD, Pacini R: Differentiation of esophageal pain from angina pectoris. Role of the esophageal acid perfusion test. Medicine (Baltimore) 41:143, 1962 Henderson RD: The gastroplasty tube as a method of reflux control. Can J Surg 21:264, 1978 Polk HC, Zeppa R: Fundoplication for complicated hiatal hernia. Rationale and results, Ann Thorac Surg 7:202, 1969 Henderson RD, Marryatt GV: Recurrent hiatal hernia. Management by thoracoabdominal total fundoplication gastroplasty. Can J Surg 24:151, 1981 Skinner DB, Belsey RH: Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J THORAC CARDIOVASC SURG 53:33, 1967
Dysphagia complicating hiatal hernia repair 9 2 7
8 Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair. An operation for the management of peptic stricture with acquired short esophagus. J THoRAc CARDIOVASC SURG 61:50, 1971 9 Henderson RD, Marryatt GV: Reflux control following gastric surgery. Can J Surg 27: 17, 1984 10 Henderson RD, Marryatt G: Total fundoplication gastroplasty. J THoRAc CARDIOVASC SURG 85:81-87, 1983
Discussion MR. KUMARASINGHAM JEYASINGHAM Bristol, England
At Frenchay Hospital, we have been doing the modified Pearson gastroplasty, as we call it, but have restricted its use almost entirely to the short esophagus with a dilatable stricture. Our experience with the partial fundoplication of the Mark IV Heisey repair has been essentially one of dysphagia only in cases in which there was preexisting dysphagia when the repair was performed. We have currently investigated in a prospective fashion our patients who have undergone the partial fundoplication technique. We have used not only the parameters mentioned in this paper, but also the radionucleotide transit time for both liquid and solid bolus. So far, our fmdings are almost the same as those that Dr. Henderson had had with liquid barium in patients who have some degree of dysphagia. How.ever, with the solid bolus, delayed transit has been noted in a significant number of patients. Long-term postoperative follow-up is certainly necessary in these patients. I would like to ask Dr. Henderson whether he has used radionucleotide studies in dysphagic patients undergoing partial or total fundoplication. DR. F. GRIFFITH PEARSON Toronto, Ontario, Canada
I know of only three other reports in the English speaking literature which review the results of reoperation in patients with failed antireflux procedures. I compliment Dr. Henderson on the quality of the results achieved during the reasonably long period of follow-up identified in his series. We have recently reviewed the results of redo antireflux operations in a series of approximately 50 patients who were operated upon at the Toronto General Hospital and who have been followed up for longer than 5 years-up to 15 and 20 years. We have observed double the incidence of unsatisfactory results in this group of patients when compared with another group of our patients followed up for longer than 5 years, in whom we did an antireflux operation for the first time. The unsatisfactory result in both groups was due to either recurrent reflux or recurrent dysphagia, or both. The actual percentage of unsatisfactory results in our "redo group" was 27%. I would like to ask Dr. Henderson what numbers of patients in his series had an associated primary motor disorder. More specifically, were there any patients in his series with achalasia who had developed reflux with esophagitis, stricture, and dysphagia after one or more prior operations on the distal esophagus. In our own series of redo antireflux operations, only
9 2 8 Henderson
three of the 50 patients had such poor results that we believed another major operation was indicated. All three of these patients had had multiple prior operations for achalasia and presented with reflux and active peptic esophagitis. I do not think it is possible to do a local operation at the esophagogastric junction which will predictably prevent reflux on the one hand and permit satisfactory swallowing on the other hand in such cases. In all three of these patients, we finally resorted to a resection of the entire thoracic esophagus. I would appreciate Dr. Henderson's comment in this regard. DR.HENDERSON(Cwsm~
I would like to thank both Mr. Jeyasingham and Dr. Pearson for discussing this paper. They both made pertinent comments. Mr. Jeyasingham, 19 of the 34 patients treated had some dysphagia before their most recent preceding operation. I take a history of each operation that these patients have had. Some had had two or three prior procedures. In all patients, the dysphagia either had been severe before the last operation or was made substantially worse with the last operation. I do not have much experience with radionucleotide evaluation, but I believe it to be a useful study. I think it would be helpful in persons with total fundoplications, because with total fundoplications reflux control is not the problem, but rather dysphagia. The difficulty is devising an operation that avoids dysphagia. It is unfair to use reflux as the only criterion for comparing the Belseyand Nissen types of wraps, and I believe
The Journal of Thoracic and Cardiovascular Surgery
that radionucleotide studies would be an effective way of evaluating total fundoplications. I have compromised, for financial reasons, and used solid roast beef sandwiches to demonstrate obstruction. This is a simple and very effective test. As Dr. Pearson said, there are remarkably few papers on the management of recurrent esophageal disease, and I think it is an extremely important area. Recurrent hernia operations are among the most difficult procedures to be done by a thoracic surgeon and account for only about 5% of esophag~1 surgery. In this group of 34 patients, more than half have been followed-up for 5 years, and the quality of results achieved is being well maintained. In this selected group, one had scleroderma and none had achaiasias. Five had had an incorrect diagnosis of either achalasia or diffuse spasm, and had had an inappropriate myotomy. Of the five with a diagnosis of achalasia, one actually had scleroderma. The other four had a diagnosis of diffuse spasm. In two the gastroesophageal high-pressure zone was left intact. With a Nissen fundoplication, they had incredible dysphagia, obstruction, and weight loss. In my experience, the most difficult problem in revision esophageal surgery is the presence of a vagotomy and pyloroplasty or gastrectomy. To achieve reflux control and simultaneously avoid dysphagia requires a carefully tailored fundoplication.
THoRAc CARDIOVASC SURG
88:922-928, 1984
Dysphagia complicating hiatal hernia repair Dysphagia may be a continuing or added problem after operations for the control of reflux. In a series of 208 patients treated surgically for recurrent hiatal hernia, 34 (16.3%) presented with dominant dysphagia either caused by or aggravated by the operation. They were evaluated by history, radiology, manometry, and endoscopy. The causes of dysphagia were diagnosed in all patients: reflux stricture in nine patients, tight or long Nissen wrap in 15, muscle injury in three, inappropriate myotomy with reflux in three, myotomy with overcompetent repair in two, and early Nissen innmusception in two patients. Surgical correction was by total fundop6cation gastroplasty in 32 patients, Nissen repair in one, and colon interposition in one. In four patients the myotomy was closed. Complete follow-up averages 5.4 years. There bas been one anatomic recurrence, 28 patients are asymptomatic, and five are much improved but have minor persistent dysphagia. Only by complete invesigation can the cause of dysphagia be recognized and treated.
R. D. Henderson, M.B., F.R.C.S., Toronto, Ontario, Canada
USPhagia is associated with a variety of esophageal disorders, both motor and mechanical. When severe dysphagia is the dominant symptom after surgical hiatal hernia repair, it can be a major diagnostic and therapeutic problem. In the present study, 34 patients were selected for evaluation from a series of 208 patients with recurrent hiatal hernias requiring surgical revision. These patients were analyzed because of having severe dysphagia as their dominant symptom. Investigation was aimed at determining the accuracy of investigative parameters, the cause of dysphagia, and the effectiveness of surgical management. In this paper, dysphagia is the symptom recognized by the patient as being associated with esophageal obstruction by food. Severe dysphagia refers to the occurrence of food obstruction every day and with most meals. Patients and methods
Thirty-four patients have been fully investigated and treated surgically for severe dysphagia aggravated by, produced, or occurring as a late complication of hiatal hernia repair. Each patient was investigated by history, radiology, manometry with pH studies, acid perfusion, and endoscopy prior to surgical management. At the time of operation, the previous hernia repair was carefullv mobilized and inspected to determine further
From Women's College Hospital, Toronto, Ontario, Canada. Read at the Sixty-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N. Y., May 7-9, 1984.
922
its original design and the anatomic problems associated with dysphagia. History was obtained with a prepared format. All patients had one or more previous hernia repairs, and the preoperative symptoms of heartburn, reflux, nausea, vomiting, and dysphagia were demonstrated for each operation, as well as the symptoms at the time of presentation. Radiologic studies, conducted by one group of radiologists, included liquid barium and, when the diagnosis was in doubt, the addition of a barium sandwich to localize the site of obstruction. Manometric studies' were performed in conjunction with pH reflux (common cavity test)' and acid perfusion (Bernstein test).' Three polyethylene catheters were used for infusion manometry (inner diameter 1.19 mm), and water flow was maintained at 6.8 ml per tube per minute with a modified direct-drive Harvard syringe pump. A Beckman pH monitor and electrode were used for pH measurement. Esophagogastroduodenoscopy with a fiberoptic scope was performed in each patient before the operation. All surgical exposures were obtained by a left thoracoabdominal incision. After the diaphragm was divided circumferentially, the lower esophagus and gastric fundus were fully mobilized under direct vision. Thirty-three patients had a total fundoplication gastroplasty (TFG)4 and one a standard Nissen repair.' In five a previous esophageal myotomy was closed (including the standard Nissen patient), and one patient had resection of a traumatic diverticulum. The technique of TFG for recurrent hiatal hernia
Volume 88 Number 6 December, 1984
Fig. 1. Thoracoabdominal total fundoplication gastroplasty. A thoracoabdominal incision is made. Four to five short gastrics aredivided. Vagal nerves andvagal branch to liver are preserved. A 5 em gastroplasty tube is cut over a No. 60 Fr. bougie. LGA, Left gastric artery. repair has been previously described." With TFG the gastroplasty tube is cut from the lesser curvature of the stomach and calibrated over a No. 60 Fr. bougie. The gastroplasty is closed with 2-0 chromic sutures with 3-0 silkinvagination (Fig. 1). The fundus is passedclockwise posterior to the gastroplasty tube and positioned for suture fixation, The first step of fundoplication is to attach the fundus to the distal 1.5 em of the esophagus and to the full thickness of the suture line in the gastroplasty tube with 2-0 silk mattress sutures. This creates an intra-abdominal segment 6.5 em long. Completion fundoplication was reduced to 1 em in length and sutured with three 2-0 silk mattress sutures (Fig. 2). In patients with a previous gastrectomy or myotomy, the completion fundoplication was reduced to less than 0.5 em in length while the same intra-abdominal segmental length was maintained. In patients with a previous myotomy, the muscle edges of the myotomy were dissected free of mucosa. Although technically difficult, this was accomplished in each case without entering the esophageal lumen. The muscle was closed with continuous 2-0 catgut and interrupted 3-0 silk sutures (Fig. 3). In the one patient with a previous operative muscle injury, an epiphrenic diverticulum was excised. The lumen was closed to the muscle layer with 2-0 catgut and 3-0 silk. Results
The purpose of this study was threefold: to determine the diagnostic criteria necessary in evaluating major
Dysphagia complicating hiatal hernia repair 9 2 3
Fig. 2. The new fundus is sutured to the gastroplasty suture line anddistal 1.5 cmofesophagus. Completion fundoplication is reduced to 1 em length. T.F., Total fundoplication.
Fig. 3. Repair of esophageal myotomy. In patients with an esophageal myotomy the muscle margins must be mobilized and approximated with care. In the present study closure was with 2-0chromic catgut and continuous silk sutures. dysphagia complicating hiatal hernia repair, to determine the cause of dysphagia, and to establish effective methods of management. There were 12 male and 22 female patients. The age range was 17 to 69 years (average 46.3 years). The 34 patients had had seven different types of operation: Belsey hernia repair,' five patients; partial fundoplication gastroplasty (PFG),8 four patients; Nissen repair, 16 patients; TFG, three patients; extended myotomy with Belsey repair, two patients; myotomy with Nissen repair, three patients; and esophagogastrostomy, one patient. In three of the five patients with
The Journal of Thoracic and Cardiovascular Surgery
9 2 4 Henderson
Table I. Presenting symptoms Heartburn Total fundoplication Partial fundoplication Myotomy Esophagogastroscopy
8 7 3 I
19 9 5 1
Reflux
No eructation
Nausea
Vomiting
10 6 5 1
12 I 2 0
12 5 3 1
6 3 2 0
Legend: All patients had dysphagia. Reflux and heartburn were more common in those with partial fundoplication procedures. All esophageal pain was considered to be heartburn. as pain from food obstruction and reflux could not be clearly distinguished.
Table II. Radiologic investigation Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Normal
Recurrent reflux
Recurrent stricture
Diverticulum
Retention
16 4 1 0
2 1 I 0
0 4 1 1
I 0 0 0
0 0 2 0
Legend: Liquid barium studies did not always demonstrate obstruction. In those with normal studies, solids were added and obstruction always was demonstrated.
Table
m. Endoscopic evaluation
Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Competent junction
Incompetent junction
Ulcerative esophagitis
18 0 3 0
I 9 2 1
1 0 0 0
Stricture
Retention
0 4 1
0 0 3 0
I
Legend: With total fundoplication 94.7% had a competent junction with no evidence of reflux. In the partial fundoplication group, l()()% had an incompetent junction.
myotomy, the high-pressure zone had deliberately not been incised. The results of the investigation will be reported in four major categories defined by the type of fundoplication, the presence of a myotomy, and the use of an esophagogastrostomy. These categories are as follows: (1) total fundoplication (Nissen: TFG), 19 patients; (2) partial fundoplication (Belsey: PFG), nine patients; (3) myotomy of esophagus, five patients; and (4) esophagogastroscopy, one patient. The preoperative diagnosis had been reflux in 29, diffuse esophageal spasm in four, and achalasia in one. After investigation in the five with myotomy, the original diagnosis proved to be inaccurate. In total, these patients had had 59 previous operations at the time of presentation, including five patients with previous gastric operations. Before the most recent operation all had symptoms of esophageal pain and 19 had dysphagia. After the most recent operation, dysphagia had become the dominant symptom and necessitated further investigation and surgical management. In addition to gastroesophageal dysphagia, six had cricopharyngeal dysphagia, 19 described esophageal pain related to food intake, 21
described reflux, 14 aspiration, 15 inability to eructate, 10 hiccoughs, eight water brash, 23 nausea, 12 vomiting, and eight inability to vomit. These symptoms are correlated to the operative design (Table I). Radiologic studies with liquid barium disclosed abnormalities in only 13 patients. Ten had a recurrent hiatal hernia or reflux and six of these had a radiologic stricture. One had a traumatic diverticulum. Obstruction with solid foods could be demonstrated in all, ranging from delayed esophageal emptying to total obstruction and food retention or regurgitation (Table
11).
The esophagogastric junction was assessed endoscopically to determine competence or incompetence, and the esophageal mucosa was assessed for ulcerative esophagitis or stricture. Esophageal mucus and food retention was also noted (Table III). Manometric and pH studies demonstrated anatomic recurrence and reflux in 10 and too long a wrap with an incorporated lower esophagus in three. In the five with a previous myotomy, it was possible to exclude diffuse esophageal spasm and achalasia. In one patient, previously believed to have achalasia, a diagnosis of scleroderma with reflux was made (Table IV).
Volume 88 Number 6 December, 1984
925
Dysphagia complicating hiatal hernia repair
Table IV. Manometric evaluation No. Total fundoplication Partial fundoplication Myotomy Esophagogastrostomy
Recurrent hiatal hernia or reflux
Incorporated esophagus
Incorrect diagnosis
4
3 0 0 0
0 0
19 9 5 1
5 0 I
5 0
Legend: A manometric diagnosis was made in 18 of 34 patients (53%). In those with a previous myotomy it was possible to exclude achalasia and diffuse esophageal spasm and to diagnose scleroderma in one patient.
Table V. Cause of dysphagia (combined data)
Total fundoplication Partial fundoplication Myotomy, Nissen Myotomy, Belsey Esophagogastrostomy
Traumatic diverticulum
Nonpeptic stricture
1
1 1
o
o o o
o
o o
Legend: With total fundoplication a tight or long fundoplication was the most common problem. Intussusception recurrence, although rare, is specific to total fundoplication. The nonpeptic strictures are related to diaphragmatic tightness and suture reaction. With the partial fundoplications, reflux with or without stricture produced dysphagia. In the myotomy group, reflux, an overcompetent repair, or an intact high-pressure zone was the problem. In the patient with an esophagogastrostomy, a stricture developed at the anastomotic site. Intuss., Intussusception. Rec., Recurrence. Cont., Continued.
At the time of operation, the previous repair was carefully dissected to determine the anatomic defect; however, a clinical diagnosis, based on the described investigation, had been determined before operation. In all patients with a Belsey repair or PFG, a diagnosis was established preoperatively based on the preoperative investigation. This was also the case in patients with a myotomy. However, 19 patients with a prior Nissen repair or TFG were more of a diagnostic challenge. In 12 the only abnormal finding was the radiologicdemonstration of obstruction to solids. In this group the obstruction was considered to be related to the fundoplication, and this assumption was confirmed at operation. These patients all had the immediate onset of dysphagia or worsening of preoperative dysphagia after the operation. With the TFG procedures, too long or too tight a fundoplication was the most common problem. In those with PFG, continued reflux with or without stricture was the most common cause of dysphagia (Table V). Surgical results I have obtained clinical follow-up in all patients, radiologic studies in 30 (88.2%), and manometry with pH reflux testing in 21 (61.7%). Follow-up ranges from 2 to 8.5 years and averages 5.4 years. None has reflux or anatomic recurrence. Thirty patients (88.2%) are asymptomatic and eating normally. Three patients (8.8%) have minor residual
symptoms, one with scleroderma has a slowly.resolving stricture, one has gastritis, and one has nonspecific complaints, but no dysphagia. One patient (3%) with a repaired myotomy intially did well, but the myotomy repair failed and she required colon interposition. Discussion In the introduction I noted that this investigation had three main purposes: (1) to determine the accuracy of the investigative parameters, (2) to evaluate the causes of dysphagia with each of the operations used, and (3) to evaluate the effectiveness of surgical management. The investigative parameters are history, radiology, manometry, and endoscopy. History was of value in determining when dysphagia occurred in relation to the various operation. Onset of dysphagia immediately after the operation is a strong indication that the problem is related to the operative technique rather than anatomic breakdown. The type of previous operation is also part of the history. In the present study 30% of the 208 patients with recurrent hernias had had a previous TFG procedure, and 19 of the 34 (56%) with dysphagia had had a TFG operation. This strongly suggests that dysphagic problems are more common with TFG. Radiology was effective in demonstrating anatomic recurrence with breakdown of the fundoplication, but it did not demonstrate an intussusception recurrence. Strictures were all detected radiologically. In the five with a myotomy, either reflux or major retention was
The Journal 01 Thoracic and Card iovascular Surgery
9 2 6 Henderson
~ :
!:
!!
i
ii
cm w a t e r M J !
~
~g
10
o
: G ! 1
i
i
~
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i HPZ !
P
0
P
o
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:
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Fig. 4. Nissen repair-too long a fundoplication. A manometric trace is illustrated. Pressure is shown on the left side and the speed of paper motion indicated below. Vertical lines indicate proximal 1 em moves of the catheters. The high-pressure zone (HPZ) is shown as a zone of elevated pressure. Distal esophageal pressure is elevated because of the surrounding Nissen fundoplication. Proximal esophageal pressure is normal. G. Stomach. P, Peristalsis. D, Disordered motor waves.
3-4cm Fundopllcallon
Intraabdominal Segment
= Fundoplication Length
Fig. 5. With a standard Nissen using gastroesophagogastric sutures, the intra-abdominal segment and fundoplication length are equal.
demonstrated. The addition of solids was very important, and in 12 patients (35%) obstruction with solid food was the only demonstrable abnormality. In the past, manometry has demonstrated incompetence of the high-pressure zone in patients with a hiatal hernia, and Code's analysis can be used to make a diagnosis in 69% of patients.' In the present study, the fact that preoperative manometry was not usually available for comparison decreased the diagnostic accuracy in evaluating hernia recurrence. In three patients, incorporation of the lower esophagus was demonstrated (Fig. 4), indicating increased length of the fundoplication. Manometry was of particular value in the five patients with previous myotomies in whom an incorrect diagnosis of diffuse esophageal spasm or achalasia had been made.
Endoscopic investigation showed a high incidence of high-pressure zone incompetence in the group with a PFG and a competent junction in most patients with a TFG. Ulceration, stricture, food retention, and a diverticulum were also noted. Each investigative parameter was necessary , and a diagnosis, based on these studies, was made in all but 12 patients with a TFG. In this group, obstruction had been demonstrated radiologically with solids. All of these patients reported severe dysphagia immediately after the operation. In the 12, a clinical diagnosis of too tight or too long a fundoplication was made based on history, normal radiologic fmdings with liquid barium, and radiologic evidence of obstruction with solid food. Normal manometric and endoscopic results were considered to be supporting data.
Volume 88 Number 6 December, 1984
The intraoperative findings confirmed the preoperative evaluation in 32 patients (Table V). In two patients (non-peptic stricture group) the added fmding of suture reaction and a tight crural repair was recognized intraoperatively. In the two major groups the most common cause of postoperative major dysphagia was reflux with PFG and a tight or long wrap with TFG. The increased length of wrap has been shown to produce overcompetence?: 10 and is probably the most common error made in patients with a TFG procedure. For a standard Nissen fundoplication, most surgeons use a gastroesophagogastric suturing technique, which creates an intra-abdominal segment (Fig. 5) equal to the length of the completion fundoplication. With the TFG, the intra-abdominal segment is sutured separately and the completion fundoplication is tailored to a 1 em length. In the development of the TFG, the length of the completion fundoplication is the most important factor in producing overcompetence and dysphagia. Reducing wrap length to I em has almost eliminated dysphagia as a complication of TFG.9,10 In the surgical management of 33 of the 34 patients, dysphagia has been corrected by full mobilization and TFG. The only major residual problem in long-term follow-up was disruption of the myotomy repair in one patient. Considering the number and complexity of previous operations, this is a very conservative approach to surgical management. The results justify the surgical approach as an alternate to resection and interposition. REFERENCES
2
3
4 . 5
6
7
Henderson RD: Esophageal Manometry in Clinical Investigation, New York, 1983, Praeger Publishers Butterfield 00, Struthers JE Jr, Showalter JP: A test of gastroesophageal sphincter incompetence. The common cavity test. Am J Dig Dis 17:415, 1972 Bernstein LM, Fruin RD, Pacini R: Differentiation of esophageal pain from angina pectoris. Role of the esophageal acid perfusion test. Medicine (Baltimore) 41:143, 1962 Henderson RD: The gastroplasty tube as a method of reflux control. Can J Surg 21:264, 1978 Polk HC, Zeppa R: Fundoplication for complicated hiatal hernia. Rationale and results, Ann Thorac Surg 7:202, 1969 Henderson RD, Marryatt GV: Recurrent hiatal hernia. Management by thoracoabdominal total fundoplication gastroplasty. Can J Surg 24:151, 1981 Skinner DB, Belsey RH: Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J THORAC CARDIOVASC SURG 53:33, 1967
Dysphagia complicating hiatal hernia repair 9 2 7
8 Pearson FG, Langer B, Henderson RD: Gastroplasty and Belsey hiatus hernia repair. An operation for the management of peptic stricture with acquired short esophagus. J THoRAc CARDIOVASC SURG 61:50, 1971 9 Henderson RD, Marryatt GV: Reflux control following gastric surgery. Can J Surg 27: 17, 1984 10 Henderson RD, Marryatt G: Total fundoplication gastroplasty. J THoRAc CARDIOVASC SURG 85:81-87, 1983
Discussion MR. KUMARASINGHAM JEYASINGHAM Bristol, England
At Frenchay Hospital, we have been doing the modified Pearson gastroplasty, as we call it, but have restricted its use almost entirely to the short esophagus with a dilatable stricture. Our experience with the partial fundoplication of the Mark IV Heisey repair has been essentially one of dysphagia only in cases in which there was preexisting dysphagia when the repair was performed. We have currently investigated in a prospective fashion our patients who have undergone the partial fundoplication technique. We have used not only the parameters mentioned in this paper, but also the radionucleotide transit time for both liquid and solid bolus. So far, our fmdings are almost the same as those that Dr. Henderson had had with liquid barium in patients who have some degree of dysphagia. How.ever, with the solid bolus, delayed transit has been noted in a significant number of patients. Long-term postoperative follow-up is certainly necessary in these patients. I would like to ask Dr. Henderson whether he has used radionucleotide studies in dysphagic patients undergoing partial or total fundoplication. DR. F. GRIFFITH PEARSON Toronto, Ontario, Canada
I know of only three other reports in the English speaking literature which review the results of reoperation in patients with failed antireflux procedures. I compliment Dr. Henderson on the quality of the results achieved during the reasonably long period of follow-up identified in his series. We have recently reviewed the results of redo antireflux operations in a series of approximately 50 patients who were operated upon at the Toronto General Hospital and who have been followed up for longer than 5 years-up to 15 and 20 years. We have observed double the incidence of unsatisfactory results in this group of patients when compared with another group of our patients followed up for longer than 5 years, in whom we did an antireflux operation for the first time. The unsatisfactory result in both groups was due to either recurrent reflux or recurrent dysphagia, or both. The actual percentage of unsatisfactory results in our "redo group" was 27%. I would like to ask Dr. Henderson what numbers of patients in his series had an associated primary motor disorder. More specifically, were there any patients in his series with achalasia who had developed reflux with esophagitis, stricture, and dysphagia after one or more prior operations on the distal esophagus. In our own series of redo antireflux operations, only
9 2 8 Henderson
three of the 50 patients had such poor results that we believed another major operation was indicated. All three of these patients had had multiple prior operations for achalasia and presented with reflux and active peptic esophagitis. I do not think it is possible to do a local operation at the esophagogastric junction which will predictably prevent reflux on the one hand and permit satisfactory swallowing on the other hand in such cases. In all three of these patients, we finally resorted to a resection of the entire thoracic esophagus. I would appreciate Dr. Henderson's comment in this regard. DR.HENDERSON(Cwsm~
I would like to thank both Mr. Jeyasingham and Dr. Pearson for discussing this paper. They both made pertinent comments. Mr. Jeyasingham, 19 of the 34 patients treated had some dysphagia before their most recent preceding operation. I take a history of each operation that these patients have had. Some had had two or three prior procedures. In all patients, the dysphagia either had been severe before the last operation or was made substantially worse with the last operation. I do not have much experience with radionucleotide evaluation, but I believe it to be a useful study. I think it would be helpful in persons with total fundoplications, because with total fundoplications reflux control is not the problem, but rather dysphagia. The difficulty is devising an operation that avoids dysphagia. It is unfair to use reflux as the only criterion for comparing the Belseyand Nissen types of wraps, and I believe
The Journal of Thoracic and Cardiovascular Surgery
that radionucleotide studies would be an effective way of evaluating total fundoplications. I have compromised, for financial reasons, and used solid roast beef sandwiches to demonstrate obstruction. This is a simple and very effective test. As Dr. Pearson said, there are remarkably few papers on the management of recurrent esophageal disease, and I think it is an extremely important area. Recurrent hernia operations are among the most difficult procedures to be done by a thoracic surgeon and account for only about 5% of esophag~1 surgery. In this group of 34 patients, more than half have been followed-up for 5 years, and the quality of results achieved is being well maintained. In this selected group, one had scleroderma and none had achaiasias. Five had had an incorrect diagnosis of either achalasia or diffuse spasm, and had had an inappropriate myotomy. Of the five with a diagnosis of achalasia, one actually had scleroderma. The other four had a diagnosis of diffuse spasm. In two the gastroesophageal high-pressure zone was left intact. With a Nissen fundoplication, they had incredible dysphagia, obstruction, and weight loss. In my experience, the most difficult problem in revision esophageal surgery is the presence of a vagotomy and pyloroplasty or gastrectomy. To achieve reflux control and simultaneously avoid dysphagia requires a carefully tailored fundoplication.