effects of total fundoplication on function of the esophagus after myotomy for achalasia

SCIENTIFIC PAPERS

Effects of Total Fundoplication on Function of the Esophagus

After Myotomy for Achalasia

Andre Duranceau, MD, Montreal, Quebec, Canada

Edwin R. LaFontaine, MD, Montreal, Quebec, Canada

Bertrand Vallieres, MD, Montreal, Quebec, Canada

Achalasia is a condition in which the lower esophageal sphincter shows a normal or elevated resting pressure, an incomplete or absent relaxation of the sphincter, and a loss of peristalsis with elevated resting pressure in the body of the esophagus [I]. Surgical treatment of achalasia aims at decreasing the high resistance to food passage from esophagus to stomach. The effects of cardiomyotomy on the lower esophageal sphincter have been well docu- mented. Lower esophageal sphincter resting pressure is lowered significantly with a pressure remnant in- terpreted as sufficient to protect against gastroesophageal reflux. The contraction pressures in the esophageal body are lowered and peristalsis does not return T2-41.

The true incidence of reflux after distal esophageal myotomy is unknown. Ellis [2], Okike [5] and their co-workers reported a 3 percent incidence of such problems after clinical and radiologic evaluation of their patients. Other reports, however, mention a 20 to 50 percent incidence of gastroesophageal reflux after surgical treatment of achalasia [4,6-B].

Antireflux surgery after myotomy for achalasia is controversial. On one hand, simple myotomy may abolish the sphincter high pressure zone, allowing proper esophagogastric transit as well as gastroesophageal reflux. On the other hand, reconstruction of a proper sphincter mechanism after myotomy may have the advantage of creating a properly functioning antireflux mechanism but may also become obstructive to the poorly functioning esophagus. The ideal repair should minimize obstruction against the descending bolus by removing the abnormal

From the Departments of Surgery, Radiology and Nuclear Medicine, Univ- ersite de Montreal, Hotel-Dieu de Montreal Hospital, Montreal, Quebec, Canada.

Requests for reprints should be addressed to Andre Duranceau, MD, Department of Surgery, Hotel-Dieu de Montreal Hospital, 3840 St. Urbain Avenue, Montreal, Quebec. Canada H2W lT8.

Presented at the 22nd Annual Meeting of The Society for Surgery of the Alimentary Tract, New York, New York, May 19-20, 1981.

22

sphincter while creating a new valvular mechanism which will allow adequate transit through the sphincter zone and successfully oppose reflux.

A number of antireflux procedures have been reported for the prevention of reflux after cardiomyotomy for achalasia. Partial fundoplication is used frequently [6,9-211. Black et al [B] report excellent results with the Collis plastic repair. Total fundoplication is reported mainly in the European litera- ture [12,13]. Menguy [14] describes the use of total fundoplication in six patients after esophageal myotomy without transit problems. Other workers, however, mention this operation as being responsible for obstructive symptoms [15], unless it is very much modified [16].

This work documents the clinical and manometric effects of a short fundoplication on function of the esophagus after myotomy for achalasia.

Material and Methods

Patients: Esophageal motility studies were performed before and after cardiomyotomy and total fundoplication in 12 patients with achalasia (6 men and 6 women, mean age 44 years). The diagnosis was established by radiologic and manometric evaluation. Cholinergic stimulation con- firmed the denervation pattern in six patients. The group served as its own control. Motility studies were performed in a fasting state before and after surgery. No medication was used before the studies.

Recording system: Motor function of the esophagus was recorded using a continuously perfused system. A triple lumen polyethylene tube (USC1 1100) has all three lumen ending laterally with the openings 5 cm apart and in a radial orientation. Each lumen has an internal diameter of 1.5 mm. The lateral orifice through which the pressures are recorded has a diameter of 8 mm. A Harvard infusion pump perfuses continuously the esophageal motility tube at a rate of 3.8 ml/min/lumen in the distal sphincter and in the esophageal body. For the proximal sphincter area the perfusion volume is increased to 7.6 ml/min/lumen while pharyngeal function is recorded through a water-filled but unperfused lumen. The pressures sensed by the column of water in the motility tube

The American Journal of Surgery

Esophageal Function After Myotomy

F/gore 1. The distal esophagus is freed in its kttraabdomktal and lntrathoraclc portions.

are transmitted to external transducers (Hewlett-Packard 1280) and recorded on a four channel polygraph (Hew- lett-Packard 7754 A). All pressures were recorded in mm Hg and compared with the atmospheric zero reference point. Calibration of the recording system was done before and after each study.

Procedures: The pressure transducers are at head level. The motility tube is passed through the nose to allow better control of ports location. Recordings are made with the patient in a supine position. Stomach resting pressure is recorded, followed by 10 stationary recordings of the lower esophageal sphincter area. The lower esophageal sphincter is recorded through two separate ports with different or- ientations. The motility tube is then pulled back to record selectively 10 swallows in the distal 10 cm of the esophagus and 10 swallows in the proximal 10 cm of the esophageal

F&ure 3. The freed muscle f/ap is cut transversely at the proximal and dkztai ends of the myotomy and ro6ed back around the inlact esophageal muscle.

Figure 2.77~? myotomy is started on the teft lateral positbn of the esophegus and 50 percent of the esophageal circumference is unwrapped.

body. The recording of the upper esophageal sphincter is done using a rapid perfusion technique, and 10 swallows are used to study the area. The tube orifice recording the upper esophageal sphincter zone is always in an antero- posterior position, facing the posterior wall of the pharynx. Recording speed is 1 mm/second in the lower esophageal sphincter and esophageal body and 5 mm/second in the upper esophageal sphincter area. Two ml of water are given as a bolus to induce voluntary swallowing. The duration of recording varies from 40 to 60 minutes.

Manometric interpretation: Strict criteria are observed to study the function of the esophagus and both its sphincters. The upper esophageal sphincter is analyzed for

---r 2cm

__.i__. \

Figure 4. With a size 56 mercury bougie in the lumen of the esophagus, a short, 2 cm total fundopltcatlan is created around the denuded distal esophagus.

Volume 143, January 1982 23

Duranceau et al

absolute resting and closing pressures. Relaxation is termed complete when the sphincter pressure relaxes to within 5 mm Hg of resting cervical esophageal pressure. Relaxation time is calculated. Upper esophageal sphincter coordination is termed normal when peak pharyngeal contraction corresponds to the nadir of upper esophageal sphincter relaxation, and when upper esophageal sphincter relaxation entirely encompasses the time of pharyngeal contraction. Both the proximal and distal halves of the esophageal body are analyzed according to the same criteria: resting pressure, peak contraction pressure and coordination after voluntary deglutition. The incidence of secondary and spontaneous tertiary waves is measured and the amplitude of these waves assessed. The lower esophageal sphincter area is studied for its absolute resting and closing pressures. The difference between gastric and lower esophageal sphincter resting pressure gives the lower esophageal sphincter gradient. Relaxation of the lower esophageal sphincter is termed normal when the sphincter pressure falls to within 5 mm Hg of resting intragastric pressure. Relaxation time is recorded. Coordination is in- terpreted as normal when the relaxation period of time of the lower esophageal sphincter entirely encompasses the duration of distal esophageal contraction.

Statistical analysis: Mean values of all variables were obtained from the four study zones, and Student’s t test for paired values was used for statistical comparison.

Surgical procedure: Through a left thoracotomy the distal esophagus is identified and isolated distal to the aortic arch. A transdiaphragmatic incision is used to free the gastric fundus and the intraabdominal portion of the esophagus. The phrenoesophageal ligament is opened in its anterolateral portion. An 8 to 10 cm myotomy is done on the left lateral portion of the esophagus, and 50 percent of the esophageal circumference is freed from the muscularis. The dissected muscle is cut transversally at the distal and proximal ends of the myotomy, to be rolled back as a muscle flap and fixed to the undissected portion of the esophagus. A Hurst size 56 bougie is used as a stent to fa- cilitate myotomy and remains in place as a mold while a short total fundoplication is made around the denuded

TABLE I Clinical Evaluation

distal esophagus. A 2 cm valve is created, anchoring three 2-O silk sutures on the eversed muscularis (Figures 1 to 4). The Hurst bougie is removed, a Levin tube is directed into the stomach, and the chest is closed in the usual fashion.

Results

Clinical evaluation (Table I): Surgery was un- eventful for all patients. No mortality occurred. One wound infection was the only significant morbidity. At the time of discharge all patients were instructed to eat slowly and quietly. Drinking after the meal was encouraged as well as walking for 10 minutes. Eating before bed was discouraged.

All patients were seen 6 months and 1 year postoperatively. Four patients have now been evaluated at 2 years (mean follow-up 19 months). All preoperative symptoms disappeared after the procedure. At 1 year, two patients mentioned one episode of dysphagia and one episode of odynophagia each. Four patients mentioned a feeling of slow emptying sub- sternally without any other symptom. No regurgitation or heartburn occurred in any patient after surgery. No aspiration was noted.

Manometric results: Table II summarizes the pre- and postoperative manometric values. The upper esophageal sphincter area was unaltered by the procedure. In the proximal esophagus, the resting and contracting pressure decreased significantly after myotomy and total fundoplication. Primary waves of swallowing reappeared in 36 percent of the swallows after the operation. The incidence of spontaneous tertiary waves was also lowered significantly by surgery. The distal esophagus showed significant lowering of resting and contracting pressures. The absence of peristalsis was unaltered, while the incidence of spontaneous tertiary contractions diminished significantly. In the upper esophageal sphincter, resting and closing pressures decreased by more

1 2 3 4 5 Patients

6 7 6 9 10 11 12 Total

Before operation Follow-up (mo) Dysphagia Odynophagia Substernal pain Regurgitation Aspiration Heartburn Weight (kg)

After operation Slow emptying

sensation Dysphagia Odynophagia Substernal pain Regurgitation Aspiration Heartburn

14 24 17 16 13 1 1 1 1 1 1 0 1 1 0 1 0 1 1 1 1 1 1 1 1 0 0 0 0 1 0 0 0 0 0

37.6 . . . 56 65 63.5

0 0 0 1

0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0

0

0 0 0 0 0 0

67.6

12 27 19 24 15 16 26 19’ 1 1 1 1 1 1 1 12 0 1 1 1 1 1 1 9 1 0 1 1 1 1 1 10 1 1 1 1 1 1 12 0 : 0 1 1 1 ; 5 0 0 0 0 0 0 0

62 44.5 57 64.9 75.6 54 52 57.5’

1 0 0 1 0 1 0 4

0 0 0 1 rare 0 0 0 0 0 0 0 1 rare 0 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Weight (kg) 40 . . . 59.7 65 55 465 64.5 64.9 73.4 64 61.4 60’

l Mean values.

24 The American Journal of Surgery


than 60 percent, leaving a total gradient of 7.4 mm Hg between esophagus and stomach (Figures 5 and 6). Relaxation and coordination were unaltered.

Radiologic evaluation: All patients were re- evaluated radiologically during the follow-up period. The diameter of the esophagus was 3.9 cm before the operation. It decreased to 3.4 cm 6 months after surgery, and after follow-up of 19 months the mean diameter of the esophagus was 4.6 cm.

&flux evaluation: Technetium-99m transit time and reflux documentation procedure were performed in 10 patients. The mean transit time (standing position) after myotomy and total fundoplication was rapid in five patients, with a mean retention of 6 percent at 4 minutes, Esophageal emptying was slow in five other patients with a mean retention of 15 percent at 4 minutes. The incidence of reflux was studied for a 30 minute period with the patient in the supine position after the transit study. A single episode of reflux was observed in only one patient.

Endoscopic evaluation: All 10 patients underwent endoscopic reevaluation at their last follow-up. The distal half of the esophagus was tubular and dilated in all patients without evidence of esophagitis. The gastroesophageal junction tightened with a Valsalva maneuver, and no resistance was encoun- tered when passing from esophagus to stomach through the fundoplication.

Comments

Achalasia is characterized by absent peristalsis in the whole body of the esophagus with positive resting pressure and esophageal retention. The lower esophageal sphincter shows absent, incomplete or uncoordinated relaxation. The manometric effects of myotomy followed by total fundoplication are similar to what has been described in previous reports [2,3]. The lower esophageal sphincter pressure is lowered significantly with a remaining pressure zone of 7.2 mm Hg. The resting pressure in the body of the esophagus is also lowered after surgery. An interesting observation is the reappearance of peristalsis in 36 percent of the waves in the proximal esophagus after myotomy, while propulsion in the distal half remains absent. These observations suggest that the disappearance of the functional obstruction at the distal end of the esophagus may return normal function to at least part of the esophagus. This effect is also suggested by a decrease in resting pressure in the esophageal body and a lower incidence of spontaneous tertiary contractions between deglutitions.

The surgical lowering of the high pressure zone between esophagus and stomach may cause gastroesophageal reflux. The true incidence of this complication after cardiomyotomy remains unknown. It is very low in some reports [2,5] but distressingly high in others [4,6--8]. Only by long-term follow-up of well-planned prospective studies will this problem be solved. The surgeon may have two attitudes: a

TABLE II Achalasla: Esophageal Motor Function After Myotomy and T&al Fundopllcation’

Mean SD SE p

Upper Esophageal Sphincter

Coordination (%) Preop Postop

Relaxation (%) Preop postop

Resting pressure Preop Postop

Closing pressure Preop postop

95.7 10.6 3.3 100.0 0 0

NS

97.0 9.5 3.0 96.0 12.6 4.0

NS

65.9 31.6 10.0 77.8 43.3 13.7

NS

90.4 39.2 13.1 NS 115.2 50.6 16.9

Proximal Esophagus

Resting pressure Preop PostorJ

11.3 3.9 0.8 3.4

;:; <O.OOl

Contra&on pressure Preop Postop

Primary waves (%) Preop 0 0 0 Postop 36.0 33.7 10.7

<O.Ol

Secondary waves (n/min) Preop Postop

’ ’ ’ NS 0 0 0

Spontaneous tertiary waves (n/min) Preop 4.1 3.0 Postop 0.4 0.9

Distal Esophagus


Contraction pressure Preop Postop

Primary waves (%) Preop Postop

Secondary waves (n/min)

13.2 6.1 2.4 4.4 ;:; <O.OOl

45.7 15.8 22.4 4.0 ::; <O.OOl

0 0 0 0 0 0 NS

Preop 0 0 0 POStOD 0 0 0 NS

Spontaneous tertiary waves (n/min) Preop 3.5 2.4 Postop 0.9 1.1

;:t <0.05

Lower Esophageal Sphincter


Sphincter gradient

Preop Postop

Closing pressure

30.2 4.9 12.7 5.t

;:; <O.OOf

24.8 6.9 7.4 2.9 ;:; <O.OOl

Pre& Post0p

44.0 10.3 3.4 =o,oo, la.1 9.5 3.2

Relaxation (%) Preop postop

$“5::, ;::; ;i:; NS

Coordination (% ) Preop la.1 28.0 Postop 11.0 21.3

68:; NS

* Before and after operation. All pressures in mm Hg. NS = not significant; SD = standard deviation: SE = standard error.


Duranceau et al

ST0

ws mm Hg I

20

44cm 0

20

49cm

0

20

IMACH 0

1

mm Hg mm Hg

conservative one, observing the natural evolution of esophagus [X,16]. Menguy [14] reports his experi- the diminished gastroesophageal sphincter area; or ence with six patients without transit problems, and a preventive one, reconstructing an antireflux European surgeons report the use of the same oper- mechanism after myotomy. ation with excellent clinical results [12,13].

Partial fundoplication has been shown to be an excellent anatomic repair but allows persistent reflux in a high proportion of cases [17]. Hatafuku et al [18] mention satisfying results with near-total fundoplication, even in the megaesophagus. Total fundoplication after mvotomv is reported to cause obstructive symptoms when p&forked over a myotomized

In our group the lack of obstructive symptoms after total fundoplication against a powerless esophagus may be attributed to two factors: First, removal of the abnormal myogenic effect by denuding the mucosa over the distal esophagus causes a significant decrease in the resting pressure of the sphincter zone, and may oppose healing of the myotomy under the fundoplication. Second, the use of a large bougie as a mold to create the fundoplication may allow maximal protection to the lumen integrity, while creating an adequate antireflux valve. In ad- dition, the 2 cm fundoplication is shortened significantly from the standard repair. The resulting sphincteric gradient in the total fundoplication seems adequate to protect against reflux esophagitis, while allowing proper transit from esophagus to stomach. While it is known that the standard Nissen operation provides good protection against long-term reflux, the results of a short fundoplication still need to be evaluated with a longer follow-up period.

20

44cm 0

20

49cm 0

20

STOMACH 0

40

20

42cm 0

20

47cm 0

20

LES 0

F&ore 6. After myotomy and short total fundoplkatbn the lower esophageal sphincter (LES) gradbnt fs low, the restfng esophageal pressure nears normal, and the apertstalsls of the distal esophagus Is unchanged. WS = wet swatbw.

26

Figure 5. Motilfty tracing of a patlent wfth achalasta. llw lower esophageal sphincter gradbnt Es elevated and the bodyofthees@sScsshowsa h fgh resting preswre and non- functbnal contracttons. LES = bweres@ageal#kcteC~ = cough; WS = wet swallow.

Successful treatment of achalasia is accompanied by a decrease in esophageal diameter [19] and a lower resting pressure in the esophageal body [2,3]. My- otomy associated with total fundoplication significantly decreased the resting pressure of the esophageal body. These observations persist after a 19 month follow-up. The esophageal diameter, however, has shown a slight increase since the operation. A longer follow-up is needed to assess long-term esophageal emptying capacity, dilatation and pro-

The American Journal of Surgery


tection against reflux. At present, myotomy and short total fundoplication over a large bougie appear to provide an adequate antireflux procedure without causing obstruction to esophageal transit.

Summary

Twelve patients underwent distal esophageal myotomy for achalasia. After denuding the esophageal mucosa over 50 percent of its circumference, a short (2 cm) total fundoplication was performed over a size 56 mercury bougie. Clinical evaluation showed marked symptomatic improvement. Obstructive symptoms are minimal, and no reflux symptoms were noted. Manometric documentation showed a significant decrease in resting esophageal and lower esophageal sphincter pressure. Contraction pressure was also lowered, and peristalsis returned in 36 percent of the waves in the proximal esophagus. Ra- diologic and scanning documentation revealed slow emptying without evidence of significant reflux. Endoscopic evaluation revealed no esophagitis after 19 months’ follow-up.

Acknowledgmenti The technical assistance of Monique Pharand and the secretarial help of Anne-Marie Maurice are gratefully acknowledged.

References

1. Hurwitz AL, Duranceau A, Haddad JK. Disorders of esophageal motility. In: Major problems in internal medicine. Vol 16. Philadelphia: WB Saunders, 1979.

2. Ellis FH, Kiser FC, Schlegel JF, Earlam RJ, McVey JL, Olsen AM. Esophagomyotomy for esophageal achalasia: experi- mental clinical and manometric aspects. Ann Surg 1967; 166:640-56.

3. Csendes A, Larrain A, Strauszer R, Ayala M. Long term clinical, radiological and manometric follow-up of patients with achalasia of the esophagus treated with esophagomyotomy. Digestion 1975;13:27-32.

4. Atkinson M. The esophago-gastric sphincter after cardiomyotomy. Thorax 1959;14:125-31.

5. Okike N, Payne WS, Neufeld DM, Bernatz PE, Pairolero PC. Sanderson DR. Esophagomyotomy versus forceful dilatation for achalasia of the esophagus: Results in 699 patients. Ann Thorac Surg 1979;28:119-25.

6. Peyton MD, Greenfield LJ, Elkins RC. Combined myotomy and hiatal herniorrhaphy: a new approach to achalasia. Am J Surg 1974;128:786-90,

7. Ellis F, Cole FL. Reflux after cardiomyotomy. Gut 1965;6: 80-4.

8. Black J, Vorbach AN, Collis JL. Results of Heller’s operation for achalasia of the esophagus: the importance of hiatal repair. Br J Surg 1976;63:949-53.

9. Mansour KA, Symbas PN, Jones FL, Hatcher CR. A combined surgical approach in the management of achalasia of the esophagus. Am Surg 1979;42:192-5.

10. Murray GF. Operation for motor dysfunction of the esophagus. Ann Thorac Surg 1980;29: 185-9 1.

11. Jeckler J, Lhotka J. Modified Heller procedure to prevent postoperative reflux esophagitis in patients with achalasia. Am J Surg 1967;113:251-4.

12. Rossetti M. Osophagocardiomyotomie und fundoplicatio: eine physiologische operation bei cardiospasmus und megaoe- sophagus. J Suisse Chir 1963;93:925-31.

13. Del Genio A. On the role of intraoperative manometry in Heller and Nissen operations in the surgical treatment of achalesia: clinical radiological and manometric follow-up. Personal

communication, Chicago, 1979. 14. Menguy R. Management of achalasia by transabdominal car-

diomyotomy and fundoplication. Surg Gynecol Obstet 1971;133:482-4.

15. Ellis FH, Gibb SP. Reoperation after esophagomyotomy for achalasia of the esophagus. Am J Surg 1975;129:407- 12.

16. Henderson RD. Nissen hiatal hernia repair: problems of re- currence and continued symptoms. Ann Thorac Surg 1979;28:587-93.

17. De Meester TR, Johnson LF, Kent AH. Evaluation of current operations for the prevention of gastroesophageal reflux. Ann Surg 1974;180:511-25.

18. Hatafuku T, Maki T, Thal AP. Patch operation in the treatment of advanced achalasia of the esophagus. Surg Gynecol Obstet 1972;134:617-24.

19. Sultan M, Norton RA. Esophageal diameter and the treatment of achalasia. Am J Dig Dis 1969;14:611-8.

Discussion

Tom R. deMeester (Chicago, IL): I rise to comment on the pathophysiology of achalasia and on the application of gastric fundoplication in the presence of this abnormal condition. It is useful to think of the body of the esophagus as a pump with a valve. In achalasia the problem is that we have a poor or uncoordinated pump, and a valve that does not relax. The goal of therapy is to reduce the outflow obstruction of the unyielding valve so that it is more com- patible with the poor pump and improves its ability to transmit food from pharynx to stomach. If the myotomy is designed to reduce the resistance of the valve, then the reconstruction of a valve over a myotomized cardia is somewhat counterproductive. If we believe that this must

be done to prevent reflux, then we must be careful to match the power of the body of the esophagus with the resistance of the reconstructed valve.

In looking at this problem in our laboratory, we measured the resistance of the 360” N’issen or the 240” Belsey fundoplication constructed on a totally relaxed valve-that is, outside the body. The resistance was measured for different lengths of each valve at various intraabdominal pressures. A Nissen fundoplication of 2 cm in length at 5 cm of abdominal pressure produces a resistance of about 12 cm of water. Since the esophagus is only 25 cm long, this valve will support a column of water about half this dis- tance before allowing passage of content into the stomach. This resistance increases as the length of the Nissen wrap increases. In contrast, the Belsey 270“ wrap has only minimal resistance regardless of its length or intraabdominal pressure.

Thus, our concern in applying the Nissen wrap to a poor pump is that we are adding too much resistance which in the long-term will contribute to the severe pump failure that occurs naturally with time in this disease. Perhaps the short Nissen wrap that the authors used, plus the presence of some active contractions, although uncoordinated, in the body of the esophagus in most patients in the study, and perhaps the presence of primary peristalsis in the upper third of the esophagus in some patients in the study (a find that challenges the correctness of the diagnosis), may have contributed to their good results wit,h the Nissen fundoplication.

David B. Skinner (Chicago, IL): We agree completely with the thesis that it is better to do a complete myotomy well down onto the stomach and then reconstruct the cardia with an antireflux mechanism rather than try to esti-


Duranceau et al

mate where the bottom end of the sphincter zone is and limit the myotomy to that length.

dure it is probably worthwhile to combine it with esophagofundopexy.

I have two questions. It appears from your data that at least 10 of your 12 patients with chest pain had early phases of achalasia, so-called vigorous achalasia. Two of our col- laborators, Dr. O’Sullivan working with isotope studies and Dr. Little working with manometry, are developing evidence that in these cases the spasm in the body of the esophagus is perhaps as important in causing dysphagia as in the nonrelaxing distal segment. Therefore, the benefit you achieved for these patients may well have rested on the relief of the spasm in the body of the esophagus as much as on what you did at the distal esophageal segment.

Robert J. W. Blanchard (Winnipeg, Manitoba, Can- ada): Can you tell us whether these procedures were done from above the diaphragm or below? If from above, what is your ability to estimate the actual length of the wrap?

In these early cases the esophageal diameter is usually not great, but with time and the progression of this disease, muscle atrophy develops and the esophagus tends to dilate. We found in following up some of our own patients in whom we did fundoplications several years ago that some had progressive late dilatation of the esophagus after the total wrap, reinforcing Dr. DeMeester’s thesis that this is too much of an antireflux valve, and may cause trouble over a long-term follow-up. Thus I am afraid your 19 month follow-up might not be enough to see what is going to happen to these patients, and you may find 5 years from now that the esophagus has continued to dilate progres- sively.

Lawrence F. Johnson (Washington, D.C.): Did you have preoperative scintiscans in your patients to compare with those obtained postoperatively, as well as control scans in normal persons? We published a report entitled, “Esophageal Emptying in Achalasia Quantitated by a Radioisotope Technique” (Dig Dis Sci 1979;24:945). This technique can differentiate changes in esophageal emptying in patients with achalasia after pneumatic dila- tion and in turn can compare the postdilation emptying profile with that observed in normal control subjects. Similarly, I think that this scan technique would objec- t.ively evaluate the efficacy of fundoplication in achalasia patients having an esophageal myotomy. I share the concern of Dr. DeMeester that a Nissen 360” fundoplication impairs esophageal emptying in patients with achalasia, the exact functional defect the myotomy is performed to improve.

W. Silber (Cape Town, South Africa): I have two brief comments and a question. In the first place, achalasia as one sees it in the Western world is a disease of the nerve plexuses of the body and nonrelaxation of the lower esophageal sphincter, and as such the disease Dr. Skinner just mentioned is incurable, progressive and irreversible. I think it is extremely important to understand this, and also not just to show 12 or 15 cases but to designate the status of the esophagus in each case, because I think the prognosis depends on the status of the esophagus when first seen and operated on. In our personal series of 184 patients seen over the last 20 years in whom we performed a modified procedure, we have not seen a single case of reflux or heartburn.

Andre Duranceau (closing): In answer to Dr. DeMeester’s questions and remarks, we agree fully with him that the effect of myotomy is to remove the sphincter, and that to minimize the resistance to food passage after myotomy and fundoplication the initial operation must be modified, and that is especially why the muscle is everted and the fundoplication is made much shorter and over a very large bougie.

Concerning the chest pain and the remarks by Dr. Skinner, the esophagus in all of those patients was small, and I would not deduct that this is an operation which could be useful in the very large and dilated esophagus. The initial diameter in these patients was 3.4 cm, and after a follow-up of 19 months it increased to 4.4 cm; thus there was a small dilatation after myotomy and total fundoplication.

The question I would like to ask is, what in fact is the rationale for completely destroying the sphincter and then producing an iatrogenic sphincter?

Edgardo S. Alday (Philadelphia, PA): How long is the segment of esophagus that is telescoped into the stomach after the 360’ Nissen esophagofundopexy? I believe that the length of esophagus that is telescoped into the stomach is a more important concern than how loose the esophagofundopexy is done. Bombeck emphasized, to assure looseness, the use of a large bore catheter placed at the cardioesophageal junction during esophagofundopexy. If the segment of the esophagus that is telescoped into the stomach is 5 cm or greater, the cardioesophageal junction will be converted into a Heimlich valve-like mechanism, which is a one way valve, and this will result in the devel- opment of a complication known as the gas bloat syn- drome.

The rationale of removing the sphincter, as Dr. Silber mentioned, is the rationale of myotomy for achalasia. The manometric effects of myotomy are a decrease in lower esophageal sphincter pressure while the body abnormali- ties remain unchanged.

The length of the telescoped esophagus inside the fundoplication is a maximum of 2 cm. Dr. Henderson from Toronto does mention that he personally produces a 1 cm valve in these cases where a powerless esophagus exists.

The size 56 bougie iteself, we think, serves to create a “floppy” Nissen type of repair which might be of use in preventing a too large resistance after this type of repair.

I would like to comment on the effect of esophagocar- diomyotomy for achalasia. Dr. Benedict of Boston, in a collective review, reported a high incidence of peptic esophagitis after a Heller’s procedure. This was a result of disruption of the physiologic sphincteric mechanism at the cardioesophageal junction after myotomy. Because of the high incidence of peptic esophagitis after Heller’s proce-

Dr. Johnson, the preoperative scans were done in two patients only, and those were recent evaluations. All scans were made in the postoperative period to evaluate the easiness of esophageal emptying. In the two patients evaluated pre- and postoperatively, there was a significant decrease in retention in the body of the esophagus during transit time. The controls are actually being made and did not serve in this specific study.

As far as the surgical approach is concerned, they were all made through a left thoracic approach with a transdiaphragmatic incision to expose the lower esophagus in- traabdominally.

28 The American Journal of Surgery

effects of total fundoplication on function of the esophagus after myotomy for achalasia

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