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Surgical procedure to prevent gastroesophageal reflux
Surgical Procedure to Prevent Gastroesophageal Reflux FRANCISCO
Several excellent reviews [1-121 have discussed at length all the possible factors that could be responsible for continence of the sphincteric mechanism of the gastroesophageal junction, such as : (1) the acute angle of esophageal incidence at the stomach; (2) the clamping action of diaphragmatic pillars; (3) the contraction of gastric oblique muscular fibers; (4) the mucous rosette; (5) the phrenoesophageal ligament; (6) the esophageal vestibule believed to function as an intrinsic sphincter. Several procedures currently employed, such as cardial section or esophagogastric resection, destroy some of these elements and produce incompetence of the sphincteric mechanism. The high incidence of esophagitis as a second complication of surgery, impairing or destroying the cardioesophageal junction, has led to the development of several surgical technics aimed at preventing gastroesophageal reflux. These different technics, thus far described, can be classified as follows : I. Technics to reduce volume, acidity, and peptic activity of gastric contents A. Subtotal
gastrectomy,
Billroth
I
or Billroth
II
type
with or without gastrojejunosB. Vagotomy tomy or pyloroplasty C. Resection of the distal esophagus and proximal stomach with esophagogastrectomy of the esophagogastric junction D. Resection and antrum, with vagotomy, esophagogastrostomy, and gastroduodenal anastomosis II. Technics designed into the esophagus
to avoid
gastric
A. Esophagogastric resection with and esophagojejunal anastomosis type) From the Gastroenterology Service: the Department Surgery; and the Department of Pathology, General Medical Center, I.M.S..S.. Mexico City, Mexico.
548
reflux
vagotomy (Roux-Y
of Experimental Hospital, National
HLDALGO,
ANTONIO
RIVERA
JOSEFINA
PORTILLA
A.,
MD,
Mexico
MD, A.,
MD,
City,
Mexico
Mexico
City,
Mexico
Mexico
City,
Mexico
of the esophagogastric junction B. Resection with interposition of the jejunum, colon, or pyloric sphincter C. Esophagogastric resection with implantation of a plastic prosthesis between the esophagus and stomach of fundus and valve construcD. Duplication tion at the cardioesophageal junction. One method of valvuloplasty was first described by Dillard and Merendino [I] in 1951. They proposed the building of a papilla within the stomach through edge eversion at the esophageal end. Wooler [Z] in 1956 implanted the terminal portion of the esophagus through a specially made tunnel in the gastric wall. Adler [3], two years later, used this method with synthetic materials to create a valve mechanism in the esophagus and stomach. Franke [4] in 1957 described a valvuloplasty made with a gastric fold and partial invagination of the fundus. Watkins, Prevedel, and Harper [5] in 1959 proposed a circumferential esophagofundopexis similar to the one described by Nissen and Rossetti in the same year. Lortat-Jacob, Maillard, and Fekete [6] in 1961 analyzed each procedure available up to that time, and described their own clinical and experimental experience with end to end esophagogastric anasbomosis with the building of a posterior muscle to muscle fold. Ingram [7], two years later, proposed the circular suture of a diaphragmatic muscular flap at the esophageal distal end and demonstrated its usefulness in the dog. Recently, Lippa and Thal [8] have described what they believe is a useful method to prevent reflux ; it involves the building of a triangular gastric fold sutured to the anterior and lateral esophageal aspects that would provide a valve action. The purpose of this paper is to describe an esophagogastric anastomosis designed to prevent the reflux of gastric contents into the esophagus after resection of cardias, and to present our first of this experiences with the clinical application method in human subjects.
The
American
Journal
of
Surgery
Resection of the cardioesophageal Figure 1. vagus nerves above the diaphragm.
junction
and
Figure 2. Triangular resection of the esophageal muscular layer at its posterior or dorsal aspect. The base of the triangle includes the whole diameter and height (5 cm).
Material and Methods Sixteen mongrel dogs weighing 15 to 20 kg were used. With the animal under general anesthesia using sodium pentothal and controlled respiration, a left thoracotomy at the eighth intercostal space was made, and resection of the cardioesophageal junction and vagus nerves above the diaphragm was carried out. (Figure 1.) Pyloroplasty was performed in all animals at a second abdominal operation. Five animals served as the control group. They were subjected to direct esophageal anastomosis to the anterior aspect of the gastric stump. Anastomosis of the esophageal end to the anterior aspect of the stomach was performed on the eleven remaining animals in the following way : 1. Triangular resection of the esophageal muscular layer at its posterior or dorsal aspect was performed. The base of the triangle includes the entire diameter and height of the esophagus (5 cm). (Figure 2.) 2. Resection of serous and muscular layers of the stomach similar in size to those of the esophagus was carried out. This is carried out on the anterior aspect of the stomach and slightly below the gastric stump suture. 3. Number 2-O or 3-O silk retaining sutures are made which include the seromuscular layer of the stomach and the muscular esophageal layer joining the vertices of both triangles. 4. Other suture points are made in the same way, including the same planes #andjoining both basal angles. 5. The muscular edges on both sides of the triangle are joined together with separate silk sutures. 6. The gastric mucoaa is sectioned transversely in a length equal to that of the esophageal orifice. ‘7. A continuous atraumatic 2-O or 3-O catgut suture joins both mucous edges from behind and, with an invaginating suture, all the layers of the anterior edges. 8. A series of separate silk sutures are made between the seromuscular layer of the stomach and the muscular layer of the esophagus. (Figure 3.) 9. The gastric wall is joined to the diaphragmatic orifice by separate sutures; therefore, in addition to fixing the stomach within the thorax, herniation of these organs is avoided. (Figure 4.)
Volume 121, May 1971
Figure 3. A silk retaining suture includes the seromuscular layer of the stomach and the muscular esophageal layer joining the vertices of both triangles. A series of separate silk sutures are made between the seromuscular layer of the stomach and the muscular layer of the esophagus.
The gastric wall is joined to the diaphragmatic Figure 4. orifice by separate sutures; so, in addition to fixing the stomach within the thorax, herniation of these organs is avoided.
10. After drainage of the pleural cavity, the thoracic wall is closed in planes. In the immediate postoperative days all animals received procaine penicillin and were fed a liquid diet. In the animals that survived more than three weeks, endoscopy was carried out for twenty-one days to more than two years. In the majority of the animals roent-
549
Hidalgo,
Figure 5. dogs.
Rivera,
and
Esophagitis
Portilla
was present
Normal esophageal Figure 6. of the dogs treated.
at autopsy
mucosa
in only four
was present
in most
genologic studies were carried out under chlorpromazine anesthesia (2 mg/kg)‘. The contrast medium was given through a thick catheter inserted into the esophagus, and the progress of barium was controlled by cineroentgenography or fluoroscopy; several pertinent films were taken. Manual compression of the abdomen was used to stimulate reflux. Gastric hypersecretion was induced to exaggerate the consequences of peptic activity of gastric contents; this was achieved with a daily intramuscular injection of 30 mg of histamine one or two weeks before the dogs died or were sacrificed. Results
In all animals with direct anastomosis between the esophagus and stomach, reflux was demon-
Figure 7. The occlusion of the esophageal lumen that takes place when the flaccid triangular segment of the joined mucosas moves against the esophageal wall by the mechanical pressure occurring when the gastric stump, as a fundus, distends itself.
550
strated roentgenologically and endoscopically, but esophagitis was present in only four dogs at autopsy. (Figure 5.) Of eleven animals with esophagogastric anastomosis performed by the procedure previously described, only one showed reflux and there was minimal esophagitis in two. Esophageal mucosa was normal in the remaining dogs. (Figure 6.) In one of the two dogs with esophagitis the esophagoplasty was in good condition. It is of interest that in this animal as well as in two dogs in the control group, regurgitation and vomiting occurred in the immediate postoperative days, and subsided spontaneously. Postmortem examination of the dog with reflux showed significant retraction of the mucous flap with macroscopic signs of esophagitis. All dogs given histamine had gastritis. None presented with ulcerative lesions of the stomach or duodenum. Comments
These results show that resection of the cardioesophageal junction, with direct anastomosis of the ‘esophagus to the anterior aspect of the stomach, produced reflux and esophagitis of varying degrees in the dmog. The fact that only one of the eleven animals operated on by the method described had reflux and that another had minimal esophagitis suggests that the procedure is useful in preventing postoperative reflux in the dog. Two factors favor the valve mechanism : (1) the oblique position in which the esophagus is anastomosed to the stomach; (2) the occlusion of the esophageal lumen that takes place when the flaccid triangular segment of the joined mucosas moves against the esophageal wall by the mechanical pressure occurring when the gastric stump, as a fundus, distends itself. (Figure 7.) Vagotomy and pyloroplasty lessen the effects of reflux by reducing the peptic acid secretion of the stomach and by improving its ability to empty. To evaluate the practical application of this procedure, two patients were operated on at the Gastroenterology Service, General Hospital, National Center, I.M.S.S. One of them had esophagogastric resection for benign stenosis. Roentgenologic and endoscopic studies performed one month after operation failed to show reflux. (Figure 8.) Unfortunately, the patient died two months later from extensive myocardial infarction. Since autopsy was refused, we could not determine the status of the anastomosis.
The
American
Journal
of
Surgery
Gastroesophageal
Reflux
Figure 8. Case I. Roentgenologic and endoscopic studies performed one month after operation failed to show ,reflux. Figure 9. Thirteen months after operation the anastomosis was functioning well and there were no roentgenologic signs or endoscopic evidence of reflux
The second patient was a sixty-eight year old woman who had esopbagogastric resection and anastomosis with the same technic for bleeding ulcer of the cardias and extensive esophagitis. Thirteen months after operation the anastomosis was functioning well and there were no roentgenologic signs or endoscopic evidence of reflux. (Figure 9.) We have reported our first experiences in an attempt to further the application of this method in human subjects. However, because of the small number of patients treated and the short follow-up period, definite conclusions cannot be drawn. Summary
and Conclusions
A new method to prevent gastroesophageal reflux following resection of the cardioesophageal junction is described. The presence of reflux in one of the eleven dogs operated on and in all the animals in the control group suggests the usefulness of the procedure in preventing reflux esophagitis. Two patients in whom this procedure produced immediate satisfactory results are presented. However, the short follow-up period prevents an accurate estimate of the actual usefulness of this procedure in human subjects.
Volume
121,
May
1971
References 1. Dillard DH, Merendino KA: Experience with the interposed jejunal segment combined with adjunction procedures in prevention of esophagitis. Surg Forum 41: 323, 1954. 2. Wooler G: Reconstruction of the cardia and fundus of the stomach. Thorax 24: 275, 1956. 3. Adler RH: A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 44: 63, 1958. 4. Franke H: Sobre o problema da esofagite de refluxo apos ressecao do cardia. Rev Brasil Cir 33: 523. 1957. 5. Watkins DH, Prevedel A, Harper FR: A method of preventing esophagitis following esophagogastrostomy. J Thoracic Surg 28: 367, 1954. 6. Lortat-Jacob JL, Maillard JN, Fekete F: A procedure to prevent reflux after esophagogastric resection: experience with 17 patients. Surgery 50: 600, 1961. 7. Ingram P: The experimental study of a new operation to restore esophagogastric competence and repair hiatus hernia. Surg Gynec Obstet 116: 203, 1963. 8. Lippa HF, Thal AP: Experimental reflux esophagitis. Arch Surg 93: 148, 1966. 9. Allison PR, Wooler GH, Gunning AJ: Esophagojejunogastrostomy. J Thoracic Surg 33: 738, 1957. 10. Bernes WA, Sleisenaer MH: Phvsiolonical considerations in the surgical management bf disorders of the esophagus. Surg Clin N Amer p 331, 1958. 11. Ellis FM Jr: Experimental aspects of surgical treatment of reflux esophagitis and esophageal stricture. Amer Surg,l43: 465, 1956. 12. Watkins DH, Prevedel A, Harper FR: A method of preventing esophagitis following esophagogastrostomy. J Thoracic Surg 28: 367, 1954.
551
Several excellent reviews [1-121 have discussed at length all the possible factors that could be responsible for continence of the sphincteric mechanism of the gastroesophageal junction, such as : (1) the acute angle of esophageal incidence at the stomach; (2) the clamping action of diaphragmatic pillars; (3) the contraction of gastric oblique muscular fibers; (4) the mucous rosette; (5) the phrenoesophageal ligament; (6) the esophageal vestibule believed to function as an intrinsic sphincter. Several procedures currently employed, such as cardial section or esophagogastric resection, destroy some of these elements and produce incompetence of the sphincteric mechanism. The high incidence of esophagitis as a second complication of surgery, impairing or destroying the cardioesophageal junction, has led to the development of several surgical technics aimed at preventing gastroesophageal reflux. These different technics, thus far described, can be classified as follows : I. Technics to reduce volume, acidity, and peptic activity of gastric contents A. Subtotal
gastrectomy,
Billroth
I
or Billroth
II
type
with or without gastrojejunosB. Vagotomy tomy or pyloroplasty C. Resection of the distal esophagus and proximal stomach with esophagogastrectomy of the esophagogastric junction D. Resection and antrum, with vagotomy, esophagogastrostomy, and gastroduodenal anastomosis II. Technics designed into the esophagus
to avoid
gastric
A. Esophagogastric resection with and esophagojejunal anastomosis type) From the Gastroenterology Service: the Department Surgery; and the Department of Pathology, General Medical Center, I.M.S..S.. Mexico City, Mexico.
548
reflux
vagotomy (Roux-Y
of Experimental Hospital, National
HLDALGO,
ANTONIO
RIVERA
JOSEFINA
PORTILLA
A.,
MD,
Mexico
MD, A.,
MD,
City,
Mexico
Mexico
City,
Mexico
Mexico
City,
Mexico
of the esophagogastric junction B. Resection with interposition of the jejunum, colon, or pyloric sphincter C. Esophagogastric resection with implantation of a plastic prosthesis between the esophagus and stomach of fundus and valve construcD. Duplication tion at the cardioesophageal junction. One method of valvuloplasty was first described by Dillard and Merendino [I] in 1951. They proposed the building of a papilla within the stomach through edge eversion at the esophageal end. Wooler [Z] in 1956 implanted the terminal portion of the esophagus through a specially made tunnel in the gastric wall. Adler [3], two years later, used this method with synthetic materials to create a valve mechanism in the esophagus and stomach. Franke [4] in 1957 described a valvuloplasty made with a gastric fold and partial invagination of the fundus. Watkins, Prevedel, and Harper [5] in 1959 proposed a circumferential esophagofundopexis similar to the one described by Nissen and Rossetti in the same year. Lortat-Jacob, Maillard, and Fekete [6] in 1961 analyzed each procedure available up to that time, and described their own clinical and experimental experience with end to end esophagogastric anasbomosis with the building of a posterior muscle to muscle fold. Ingram [7], two years later, proposed the circular suture of a diaphragmatic muscular flap at the esophageal distal end and demonstrated its usefulness in the dog. Recently, Lippa and Thal [8] have described what they believe is a useful method to prevent reflux ; it involves the building of a triangular gastric fold sutured to the anterior and lateral esophageal aspects that would provide a valve action. The purpose of this paper is to describe an esophagogastric anastomosis designed to prevent the reflux of gastric contents into the esophagus after resection of cardias, and to present our first of this experiences with the clinical application method in human subjects.
The
American
Journal
of
Surgery
Resection of the cardioesophageal Figure 1. vagus nerves above the diaphragm.
junction
and
Figure 2. Triangular resection of the esophageal muscular layer at its posterior or dorsal aspect. The base of the triangle includes the whole diameter and height (5 cm).
Material and Methods Sixteen mongrel dogs weighing 15 to 20 kg were used. With the animal under general anesthesia using sodium pentothal and controlled respiration, a left thoracotomy at the eighth intercostal space was made, and resection of the cardioesophageal junction and vagus nerves above the diaphragm was carried out. (Figure 1.) Pyloroplasty was performed in all animals at a second abdominal operation. Five animals served as the control group. They were subjected to direct esophageal anastomosis to the anterior aspect of the gastric stump. Anastomosis of the esophageal end to the anterior aspect of the stomach was performed on the eleven remaining animals in the following way : 1. Triangular resection of the esophageal muscular layer at its posterior or dorsal aspect was performed. The base of the triangle includes the entire diameter and height of the esophagus (5 cm). (Figure 2.) 2. Resection of serous and muscular layers of the stomach similar in size to those of the esophagus was carried out. This is carried out on the anterior aspect of the stomach and slightly below the gastric stump suture. 3. Number 2-O or 3-O silk retaining sutures are made which include the seromuscular layer of the stomach and the muscular esophageal layer joining the vertices of both triangles. 4. Other suture points are made in the same way, including the same planes #andjoining both basal angles. 5. The muscular edges on both sides of the triangle are joined together with separate silk sutures. 6. The gastric mucoaa is sectioned transversely in a length equal to that of the esophageal orifice. ‘7. A continuous atraumatic 2-O or 3-O catgut suture joins both mucous edges from behind and, with an invaginating suture, all the layers of the anterior edges. 8. A series of separate silk sutures are made between the seromuscular layer of the stomach and the muscular layer of the esophagus. (Figure 3.) 9. The gastric wall is joined to the diaphragmatic orifice by separate sutures; therefore, in addition to fixing the stomach within the thorax, herniation of these organs is avoided. (Figure 4.)
Volume 121, May 1971
Figure 3. A silk retaining suture includes the seromuscular layer of the stomach and the muscular esophageal layer joining the vertices of both triangles. A series of separate silk sutures are made between the seromuscular layer of the stomach and the muscular layer of the esophagus.
The gastric wall is joined to the diaphragmatic Figure 4. orifice by separate sutures; so, in addition to fixing the stomach within the thorax, herniation of these organs is avoided.
10. After drainage of the pleural cavity, the thoracic wall is closed in planes. In the immediate postoperative days all animals received procaine penicillin and were fed a liquid diet. In the animals that survived more than three weeks, endoscopy was carried out for twenty-one days to more than two years. In the majority of the animals roent-
549
Hidalgo,
Figure 5. dogs.
Rivera,
and
Esophagitis
Portilla
was present
Normal esophageal Figure 6. of the dogs treated.
at autopsy
mucosa
in only four
was present
in most
genologic studies were carried out under chlorpromazine anesthesia (2 mg/kg)‘. The contrast medium was given through a thick catheter inserted into the esophagus, and the progress of barium was controlled by cineroentgenography or fluoroscopy; several pertinent films were taken. Manual compression of the abdomen was used to stimulate reflux. Gastric hypersecretion was induced to exaggerate the consequences of peptic activity of gastric contents; this was achieved with a daily intramuscular injection of 30 mg of histamine one or two weeks before the dogs died or were sacrificed. Results
In all animals with direct anastomosis between the esophagus and stomach, reflux was demon-
Figure 7. The occlusion of the esophageal lumen that takes place when the flaccid triangular segment of the joined mucosas moves against the esophageal wall by the mechanical pressure occurring when the gastric stump, as a fundus, distends itself.
550
strated roentgenologically and endoscopically, but esophagitis was present in only four dogs at autopsy. (Figure 5.) Of eleven animals with esophagogastric anastomosis performed by the procedure previously described, only one showed reflux and there was minimal esophagitis in two. Esophageal mucosa was normal in the remaining dogs. (Figure 6.) In one of the two dogs with esophagitis the esophagoplasty was in good condition. It is of interest that in this animal as well as in two dogs in the control group, regurgitation and vomiting occurred in the immediate postoperative days, and subsided spontaneously. Postmortem examination of the dog with reflux showed significant retraction of the mucous flap with macroscopic signs of esophagitis. All dogs given histamine had gastritis. None presented with ulcerative lesions of the stomach or duodenum. Comments
These results show that resection of the cardioesophageal junction, with direct anastomosis of the ‘esophagus to the anterior aspect of the stomach, produced reflux and esophagitis of varying degrees in the dmog. The fact that only one of the eleven animals operated on by the method described had reflux and that another had minimal esophagitis suggests that the procedure is useful in preventing postoperative reflux in the dog. Two factors favor the valve mechanism : (1) the oblique position in which the esophagus is anastomosed to the stomach; (2) the occlusion of the esophageal lumen that takes place when the flaccid triangular segment of the joined mucosas moves against the esophageal wall by the mechanical pressure occurring when the gastric stump, as a fundus, distends itself. (Figure 7.) Vagotomy and pyloroplasty lessen the effects of reflux by reducing the peptic acid secretion of the stomach and by improving its ability to empty. To evaluate the practical application of this procedure, two patients were operated on at the Gastroenterology Service, General Hospital, National Center, I.M.S.S. One of them had esophagogastric resection for benign stenosis. Roentgenologic and endoscopic studies performed one month after operation failed to show reflux. (Figure 8.) Unfortunately, the patient died two months later from extensive myocardial infarction. Since autopsy was refused, we could not determine the status of the anastomosis.
The
American
Journal
of
Surgery
Gastroesophageal
Reflux
Figure 8. Case I. Roentgenologic and endoscopic studies performed one month after operation failed to show ,reflux. Figure 9. Thirteen months after operation the anastomosis was functioning well and there were no roentgenologic signs or endoscopic evidence of reflux
The second patient was a sixty-eight year old woman who had esopbagogastric resection and anastomosis with the same technic for bleeding ulcer of the cardias and extensive esophagitis. Thirteen months after operation the anastomosis was functioning well and there were no roentgenologic signs or endoscopic evidence of reflux. (Figure 9.) We have reported our first experiences in an attempt to further the application of this method in human subjects. However, because of the small number of patients treated and the short follow-up period, definite conclusions cannot be drawn. Summary
and Conclusions
A new method to prevent gastroesophageal reflux following resection of the cardioesophageal junction is described. The presence of reflux in one of the eleven dogs operated on and in all the animals in the control group suggests the usefulness of the procedure in preventing reflux esophagitis. Two patients in whom this procedure produced immediate satisfactory results are presented. However, the short follow-up period prevents an accurate estimate of the actual usefulness of this procedure in human subjects.
Volume
121,
May
1971
References 1. Dillard DH, Merendino KA: Experience with the interposed jejunal segment combined with adjunction procedures in prevention of esophagitis. Surg Forum 41: 323, 1954. 2. Wooler G: Reconstruction of the cardia and fundus of the stomach. Thorax 24: 275, 1956. 3. Adler RH: A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 44: 63, 1958. 4. Franke H: Sobre o problema da esofagite de refluxo apos ressecao do cardia. Rev Brasil Cir 33: 523. 1957. 5. Watkins DH, Prevedel A, Harper FR: A method of preventing esophagitis following esophagogastrostomy. J Thoracic Surg 28: 367, 1954. 6. Lortat-Jacob JL, Maillard JN, Fekete F: A procedure to prevent reflux after esophagogastric resection: experience with 17 patients. Surgery 50: 600, 1961. 7. Ingram P: The experimental study of a new operation to restore esophagogastric competence and repair hiatus hernia. Surg Gynec Obstet 116: 203, 1963. 8. Lippa HF, Thal AP: Experimental reflux esophagitis. Arch Surg 93: 148, 1966. 9. Allison PR, Wooler GH, Gunning AJ: Esophagojejunogastrostomy. J Thoracic Surg 33: 738, 1957. 10. Bernes WA, Sleisenaer MH: Phvsiolonical considerations in the surgical management bf disorders of the esophagus. Surg Clin N Amer p 331, 1958. 11. Ellis FM Jr: Experimental aspects of surgical treatment of reflux esophagitis and esophageal stricture. Amer Surg,l43: 465, 1956. 12. Watkins DH, Prevedel A, Harper FR: A method of preventing esophagitis following esophagogastrostomy. J Thoracic Surg 28: 367, 1954.
551