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Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft
J
THORAC CARDIOVASC SURG
1989;97:575-7
Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft Twenty-jive years' experience Long-term results are presented in 60 patients (4 to 50 years old) who underwent a diaphragmatic graft procedure for relief of cardiospasm (achalasia) from 1962 through 1987. The operative technique involves construction of a pedicle flap of diaphragm. The muscular defect on the lower segment of the esophagus and the transplanted diaphragmatic pedicle that is sutured to the defect must be the same size. Immediate operative results were good. Only one complication developed, a case of pneumonia that was cured. The patients were followed up from 11 months to 25 years. Two patients were lost to follow-up, 55 had excellent results, and three patients still had nausea and heartburn but were better than before the operation. This procedure has three advantages: (1) It prevents the development of fistulas and diverticula at the site of the esophageal muscular defect; (2) it effectively eliminates both restenosis resulting from scar tissue and reflux esophagitis; and (3) it allows the cardia to recover its normal function and the esophagus to return to normal size at the site of the operation.
Yu Yong-Xian, MD, and Yu Ka-Dong, MD, Shenyang, People's Republic of China
In the past the standard Heller operation was our treatment of choice for achalasia. However, because acid reflux was a frequent complication after this operation, we began using a diaphragmatic graft in 1962. Covering the incision in the muscular layer of the esophageal wall with a piece of diaphragm effectively eliminates both restenosis caused by postoperative scar and the recurrence of reflux esophagitis. It also allows the lumen at the site of repair to return to approximately normal size, as well as restoring function of the cardia. Late results have been good in our series of 60 patients who have been treated with a diaphragmatic graft for achalasis, with a follow-up of 11 months to 25 years. Patients and procedure Between January 1962 and July 1987, a total of 60 patients with achalasia were treated with a diaphragmatic graft. They included 23 male and 37 female patients, their ages ranging from 3 to 50 years, mean 5 years. The duration of symptoms was from 4 months to 25 years. Preoperative symptoms were
From the Department of Cardiothoracic Surgery, Fourth Hospital, Shenyang, People's Republic of China. Received for publication May 23. 1988. Accepted for publication Sept. 7, 1988. Address for reprints: Yu Yong-Xian, MD, Department of Cardiothoracic Surgery, Fourth Hospital, Shen Yang Liaoning, People's Republic of China.
intermittent dysphagia, dehydration, and weight loss, all of which occurred in the majority of patients. Some of the patients with severe dehydration had an electrolyte imbalance. Esophagography revealed marked dilatation of the esophagus (transverse diameter more than 6 em) in 19 patients, moderate dilatation (3.5 to 6 em) in 38 patients, and mild dilatation in three patients. Surgical technique. Since achalasia is often complicated by retention of food within the esophagus and esophageal dilatation, a gastroduodenal tube should be inserted into the esophageal lumen before the operation and kept there to aspirate the retained food. General anesthesia was used in all 60 patients. A posterolateral incision was made through the seventh intercostal space or seventh costal bed. Exposure by this incision was satisfactory and provided adequate access to the diaphragm and esophagus for placement of the diaphragmatic graft. The dilated and stenotic parts of the lower segment of the esophagus were isolated, and the diaphragm was then incised from the esophageal hiatus anteriorly and to the left (Fig. 1, A). Attention was paid to preserving the diaphragmatic artery, to avoiding trauma to the liver and spleen, and to delicate manipulation of the transplanted fragment of the diaphragm. The serous muscular layers of esophageal cardia and gastric cardia were incised about 8 em longitudinally (Fig. 1, B). The anterior semicircular layer was isolated from the mucous membrane until the mucous membrane expanded and the esophageal lumen became normal in size. With the help of the anesthetist, 30 cc of air was introduced into the esophageal lumen through the gastric tube to expand the mucous membrane. This was done to evaluate the expansion of the mucous membrane at the cardia and to
575
The Journal of
576
Thoracic and Cardiovascular Surgery
Yu and Yu
A
B
ESOPHAGUS
Fig. 1. A, Isolation of the lower portion of the esophagus and cardia. B, Incision of the esophageal muscular layer. C, Transplantation of the diaphragmatic graft. D, Completed operation.
observe whether or not the esophageal lumen was now normal in size. If any opening in the mucous membrane had occurred, it was closed immediately. If any circular muscular fibers remained to limit the expansion of the mucous membrane, they were divided to avoid hindering this free expansion. A segment of diaphragm was immediately developed according to the size of the muscular defect in the lower segment of the esophageal muscle, with a pedicle used to preserve the blood supply (Fig. 1, C). Attention was paid to preventing injury to the left lobe of the liver, to preserving the blood supply of the resected diaphragmatic muscle, to controlling bleeding carefully, and then to suturing the transplanted fragment of the diaphram into the esophageal muscular defect. As the first step, point a was sutured to point a' (Fig. I, C), and then the remaining pedicle of the diaphragm was sutured to the edges of the defect. The final steps in the operation were
closure of the diaphragm and the thoracic cavity (Fig. 1,
D).
Results The immediate operative results in 60 patients in this series were satisfactory. There were no postoperative complications except for one case of pneumonia, which was cured. The majority of the patients gained 3 to 5 kg within 3 weeks after the operation. Dysphagia disappeared and there were no abnormal reactions or operative deaths. The patients have been followed up for 11 months to 25 years. Two patients were lost to follow-up. Excellent
Volume 97 Number 4 April 1989
results were obtained in 55 patients, who had no dysphagia or regurgitation and who had an obvious weight gain. Three patients showed improvement in eating; they still had mild nausea and heartburn but were in better condition than before the operation. Fifty percent of the patients having follow-up barium studies displayed no reflux esophagitis. In 30 patients intraesophageal pressure decreased substantially from a preoperative mean pressure of 11.2 mm Hg to a postoperative mean pressure of 7.0 mm Hg. In others, the edema and hyperemia of the esophageal mucosa, detected by endoscopy preoperatively, disappeared and obstruction was relieved. Discussion Since the first report of the surgical treatment of achalasia by Thomos-Willis in 1672,1 therapy has been directed at relieving the obstruction of the esophagus and not at the recovery of normal function of the esophagus. The early staged surgical procedures of Rumpel (1897), Wenael (1910), and Heyrocsky (1913)2 were abandoned because of postoperative serous reflux resulting from destruction of the mechanism of the cardiac sphincter or bypass of the cardia. Heller's operation, applied widely in many countries, has been associated with postoperative reflux esophagitis. Its prevalence in several reports has ranged from 30% to 50% of' patients."? Frobese and associates" reported that regurgitation occurred in most of their patients. Tong? reported that Heller's operation might result not only in esophagitis but also in perforation or restenosis of the esophagus. We changed from Heller's operation to the use of a diaphragmatic graft in 1962. Because of the physiologic anatomy, the inferior phrenic artery with the visceral nerve fibers of the transplanted diaphragmatic fragment should be preserved to assure both the blood supply and the neuromuscular control to prevent reflux esophagitis. This procedure avoids the formation of a diverticulum
Esophageal achalasia
577
owing to the expansion of the mucous membrane, perforation, and restenosis owing to scar tissue. The late results after 11 months' to 25 years' follow-up were satisfactory in our series. Conclusions There are three main advantages to relieving esophageal cardiospasm with a diaphragmatic graft: (1) It prevents the development of fistula and diverticulum at the site of the muscular defect of the esophagus; (2) it effectively eliminates both restenosis caused by scar tissue and reflux esophagitis; and (3) it promotes the recovery of normal function of the cardia and normal size of the esophagus.
1.
2.
3. 4. 5.
6. 7.
8.
9.
REFERENCES Mizai-jan, et al. Follow-upresults of Grondahl's operation for achalasia of the esophagus. J Clin Surg (Japan) 1972;27:663. Tanaka T, Matsushita T, Nora M. Surgery in idiopathic esophageal achalasia. Shujutsu 1972;26:131-8 [In Japanese]. Acheson ED, Hadley GD. Cardiomyotomy for achalasia of the cardia. Br Med J 1958;1:549. Wu Y-k, et al. Surgery of the chest. Bejing: Beijing People's Health Publishing House, 1974:504. Nemir P Jr, Frobese AS. The modified Heller operation for achalasia of the esophagus. Surg Clin North Am 1962;42:1407. Atkin M. The esophago-gastric sphincter after cardiomyotomy. Thorax 1959;14:125. Huang G-j, et al. Evaluation of results of treatment of cardiospasm with Heller's operation. Chin J Surg 1965;13:536. Frobese AS, et al. Reflection on the surgical management of achalasia of the esophagus. Am J Surg 1960; 107:249. Tong X-c. Esophagocardiomyotomy with esophagofundopexy for achalasia of the esophagus. Jpn J Surg 1978; 32:903.
THORAC CARDIOVASC SURG
1989;97:575-7
Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft Twenty-jive years' experience Long-term results are presented in 60 patients (4 to 50 years old) who underwent a diaphragmatic graft procedure for relief of cardiospasm (achalasia) from 1962 through 1987. The operative technique involves construction of a pedicle flap of diaphragm. The muscular defect on the lower segment of the esophagus and the transplanted diaphragmatic pedicle that is sutured to the defect must be the same size. Immediate operative results were good. Only one complication developed, a case of pneumonia that was cured. The patients were followed up from 11 months to 25 years. Two patients were lost to follow-up, 55 had excellent results, and three patients still had nausea and heartburn but were better than before the operation. This procedure has three advantages: (1) It prevents the development of fistulas and diverticula at the site of the esophageal muscular defect; (2) it effectively eliminates both restenosis resulting from scar tissue and reflux esophagitis; and (3) it allows the cardia to recover its normal function and the esophagus to return to normal size at the site of the operation.
Yu Yong-Xian, MD, and Yu Ka-Dong, MD, Shenyang, People's Republic of China
In the past the standard Heller operation was our treatment of choice for achalasia. However, because acid reflux was a frequent complication after this operation, we began using a diaphragmatic graft in 1962. Covering the incision in the muscular layer of the esophageal wall with a piece of diaphragm effectively eliminates both restenosis caused by postoperative scar and the recurrence of reflux esophagitis. It also allows the lumen at the site of repair to return to approximately normal size, as well as restoring function of the cardia. Late results have been good in our series of 60 patients who have been treated with a diaphragmatic graft for achalasis, with a follow-up of 11 months to 25 years. Patients and procedure Between January 1962 and July 1987, a total of 60 patients with achalasia were treated with a diaphragmatic graft. They included 23 male and 37 female patients, their ages ranging from 3 to 50 years, mean 5 years. The duration of symptoms was from 4 months to 25 years. Preoperative symptoms were
From the Department of Cardiothoracic Surgery, Fourth Hospital, Shenyang, People's Republic of China. Received for publication May 23. 1988. Accepted for publication Sept. 7, 1988. Address for reprints: Yu Yong-Xian, MD, Department of Cardiothoracic Surgery, Fourth Hospital, Shen Yang Liaoning, People's Republic of China.
intermittent dysphagia, dehydration, and weight loss, all of which occurred in the majority of patients. Some of the patients with severe dehydration had an electrolyte imbalance. Esophagography revealed marked dilatation of the esophagus (transverse diameter more than 6 em) in 19 patients, moderate dilatation (3.5 to 6 em) in 38 patients, and mild dilatation in three patients. Surgical technique. Since achalasia is often complicated by retention of food within the esophagus and esophageal dilatation, a gastroduodenal tube should be inserted into the esophageal lumen before the operation and kept there to aspirate the retained food. General anesthesia was used in all 60 patients. A posterolateral incision was made through the seventh intercostal space or seventh costal bed. Exposure by this incision was satisfactory and provided adequate access to the diaphragm and esophagus for placement of the diaphragmatic graft. The dilated and stenotic parts of the lower segment of the esophagus were isolated, and the diaphragm was then incised from the esophageal hiatus anteriorly and to the left (Fig. 1, A). Attention was paid to preserving the diaphragmatic artery, to avoiding trauma to the liver and spleen, and to delicate manipulation of the transplanted fragment of the diaphragm. The serous muscular layers of esophageal cardia and gastric cardia were incised about 8 em longitudinally (Fig. 1, B). The anterior semicircular layer was isolated from the mucous membrane until the mucous membrane expanded and the esophageal lumen became normal in size. With the help of the anesthetist, 30 cc of air was introduced into the esophageal lumen through the gastric tube to expand the mucous membrane. This was done to evaluate the expansion of the mucous membrane at the cardia and to
575
The Journal of
576
Thoracic and Cardiovascular Surgery
Yu and Yu
A
B
ESOPHAGUS
Fig. 1. A, Isolation of the lower portion of the esophagus and cardia. B, Incision of the esophageal muscular layer. C, Transplantation of the diaphragmatic graft. D, Completed operation.
observe whether or not the esophageal lumen was now normal in size. If any opening in the mucous membrane had occurred, it was closed immediately. If any circular muscular fibers remained to limit the expansion of the mucous membrane, they were divided to avoid hindering this free expansion. A segment of diaphragm was immediately developed according to the size of the muscular defect in the lower segment of the esophageal muscle, with a pedicle used to preserve the blood supply (Fig. 1, C). Attention was paid to preventing injury to the left lobe of the liver, to preserving the blood supply of the resected diaphragmatic muscle, to controlling bleeding carefully, and then to suturing the transplanted fragment of the diaphram into the esophageal muscular defect. As the first step, point a was sutured to point a' (Fig. I, C), and then the remaining pedicle of the diaphragm was sutured to the edges of the defect. The final steps in the operation were
closure of the diaphragm and the thoracic cavity (Fig. 1,
D).
Results The immediate operative results in 60 patients in this series were satisfactory. There were no postoperative complications except for one case of pneumonia, which was cured. The majority of the patients gained 3 to 5 kg within 3 weeks after the operation. Dysphagia disappeared and there were no abnormal reactions or operative deaths. The patients have been followed up for 11 months to 25 years. Two patients were lost to follow-up. Excellent
Volume 97 Number 4 April 1989
results were obtained in 55 patients, who had no dysphagia or regurgitation and who had an obvious weight gain. Three patients showed improvement in eating; they still had mild nausea and heartburn but were in better condition than before the operation. Fifty percent of the patients having follow-up barium studies displayed no reflux esophagitis. In 30 patients intraesophageal pressure decreased substantially from a preoperative mean pressure of 11.2 mm Hg to a postoperative mean pressure of 7.0 mm Hg. In others, the edema and hyperemia of the esophageal mucosa, detected by endoscopy preoperatively, disappeared and obstruction was relieved. Discussion Since the first report of the surgical treatment of achalasia by Thomos-Willis in 1672,1 therapy has been directed at relieving the obstruction of the esophagus and not at the recovery of normal function of the esophagus. The early staged surgical procedures of Rumpel (1897), Wenael (1910), and Heyrocsky (1913)2 were abandoned because of postoperative serous reflux resulting from destruction of the mechanism of the cardiac sphincter or bypass of the cardia. Heller's operation, applied widely in many countries, has been associated with postoperative reflux esophagitis. Its prevalence in several reports has ranged from 30% to 50% of' patients."? Frobese and associates" reported that regurgitation occurred in most of their patients. Tong? reported that Heller's operation might result not only in esophagitis but also in perforation or restenosis of the esophagus. We changed from Heller's operation to the use of a diaphragmatic graft in 1962. Because of the physiologic anatomy, the inferior phrenic artery with the visceral nerve fibers of the transplanted diaphragmatic fragment should be preserved to assure both the blood supply and the neuromuscular control to prevent reflux esophagitis. This procedure avoids the formation of a diverticulum
Esophageal achalasia
577
owing to the expansion of the mucous membrane, perforation, and restenosis owing to scar tissue. The late results after 11 months' to 25 years' follow-up were satisfactory in our series. Conclusions There are three main advantages to relieving esophageal cardiospasm with a diaphragmatic graft: (1) It prevents the development of fistula and diverticulum at the site of the muscular defect of the esophagus; (2) it effectively eliminates both restenosis caused by scar tissue and reflux esophagitis; and (3) it promotes the recovery of normal function of the cardia and normal size of the esophagus.
1.
2.
3. 4. 5.
6. 7.
8.
9.
REFERENCES Mizai-jan, et al. Follow-upresults of Grondahl's operation for achalasia of the esophagus. J Clin Surg (Japan) 1972;27:663. Tanaka T, Matsushita T, Nora M. Surgery in idiopathic esophageal achalasia. Shujutsu 1972;26:131-8 [In Japanese]. Acheson ED, Hadley GD. Cardiomyotomy for achalasia of the cardia. Br Med J 1958;1:549. Wu Y-k, et al. Surgery of the chest. Bejing: Beijing People's Health Publishing House, 1974:504. Nemir P Jr, Frobese AS. The modified Heller operation for achalasia of the esophagus. Surg Clin North Am 1962;42:1407. Atkin M. The esophago-gastric sphincter after cardiomyotomy. Thorax 1959;14:125. Huang G-j, et al. Evaluation of results of treatment of cardiospasm with Heller's operation. Chin J Surg 1965;13:536. Frobese AS, et al. Reflection on the surgical management of achalasia of the esophagus. Am J Surg 1960; 107:249. Tong X-c. Esophagocardiomyotomy with esophagofundopexy for achalasia of the esophagus. Jpn J Surg 1978; 32:903.