BELOW-KNEE AhfPUTATION
KING ET
toniy was not used as a primary procedure, but as a secondary procedure in two patients, both of whom will probably have further surgery.
REFERENCES
CASEY, B. H., HAMILTON, H. W. and BOBECHKE, W. P. (1972), J. Bone J t Surg., 54B : 607. DUNN, D. M. (1964), J. Bone J t Surg., 4 6 ~ 621. :
ALII
FERGUSON, A. B. and HAWORTH, M. B. (rg31), J. A m e r . med. Ass., 97: 1867. HUTCHINS, W. C. (1971), in “Campbell’s Operative Orthopzdics”, 5th edition, 2 : 1064. IMHAUSER, C. (1960), “Reconstruction Surgery and Traumatology”, S. Karger, Basel, 5 : 203 JERRE, T. (1960)~ Acts orthofi. scan& SUPPI.: 6. WILSON, P. D., JACOBS, B. and SCHECTER, L. (1965), J . Bone J t Surg,, 47-4: 1129.
Below- Knee Amputation in Peripheral Arterial Disease BARRYKING, RICHARDMCINTYREA N D KENNETHMYERS Vascular Consultative Service, Prince Henry’s Hospital, Melbourne A below-knee amputation will heal in m o s t patients w i t h atherosclerotic peripheral arterial disease, using no anterior flap and a long posterior myoplastic flap. T h e technique used b y the authors is presented in detail, w i t h their experience in 32 cases.
DESPITErecent advances in vascular reconstructive surgery, many patients with peripheral arterial disease still require amputation of the leg. I n a recent review from the Royal Prince Alfred Hospital, Sydney (Little, 1()73), it was shown that about the same number of patients come to amputation each year as have arterial reconstruction. It is difficult for the vascular surgeon to approach amputation with the same enthusiasm that he has for reconstructive surgery. Understandably, it may be thought of in terms of failure and something to be expedited and dismissed. However, for the patient, amputation should be a positive beginning to rehabilitation from a crippling and psychologically devastating disease. It can mean the beginning of renewed independence, mobility and freedom from pain. Until recently most surgeons believed that amputal :,in for peripheral arterial disease should be performed above the knee because a below-knee amputation was unlikely to heal. In 1939 Homans stated that “amputation below Reprints: Mr Barry King, 24 Collins St, Melbourne, Victoria 3000.
AUST. N.Z. J. SURG., VOL.45 -No. C
3, AUGUST,1975
the knee’can almost never be expected to offer a healthy stump”. I n recent years, however, several authors have shown that good healing rates can be achieved with below-knee amputations in peripheral arterial disease (Kendrick, 1956; Lim et alii, 1967; Condon and Jordan, 1970; Hunter-Craig et alii, 1970). Little (1973) reported that two-thirds of amputations performed at the Royal Prince Alfred Hospital, Sydney, between 1967 and 1971 were below-knee amputations, compared with one-sixth before that period. The advantages of below-knee amputations are great. Retention of the knee joint allows better proprioception, which increases the ease and likelihood of the patient learning to use a prosthesis, even in the very old. Even if the patient cannot learn to use a prosthesis, he finds it far easier to manceuvre himself in bed and get in and out of a wheelchair. Walking with a below-knee prosthesis requires far less energy expenditure than with an aboveknee prosthesis ( McCollough et alii, 1971) . These advantages of a below-knee amputation are doubly important in view of the high risk of eventual bilateral amputation. 301
B~:Lo\v-KNEI~ AMPUTATION If the patient is to benefit from the advantages of below-knee amputation, the surgeon must be able to offer a satisfactory healing rate antl a mobile, painless, tactile end-organ with good proprioception. W e believe that this can best be achieved by a technique similar to that described by Burgess and Romano (1968).
CLINICAL DETAILS I n this series, 32 patients underwent belowknee amputation for occlusive peripheral arterial disease causing gangrene. Their ages ranged from 47 to 88 years, with an average age of 70. There were 20 men and 12 women, and 13 were diabetic. Amputation followed failed arterial reconstruction in 23 legs. One patient had bilateral below-knee amputation. Below-knee amputation with this technique was carried out in all cases requiring amputation unless there was a specific contraindication. Such contraindications were rheumatoid arthritis of the knee and extensive ulceration of the lower leg rendering it impossible to design adequate skin flaps. I n all, five aboveknee amputations were performed in this period.
OPERATIVE TECHNIQUE The principles of the technique are to eliiniiiate an anterior flap because of its poor blood supply, and to preserve the blood supply
KINGET
ALIX
to the skin of the posterior flap which conies from vessels in the underlying muscle. The long posterior niyoplastic flap is sutured to the anterior skin proximal to the level of bone section, to avoid adherence of scar to bone. T h e leg is prepared in the usual manner, with the foot excluded from the operative field by a plastic foot bag tied a t the ankle. A n anterior transverse o r concave incision is made 1 2 to 15 cm helow the knee joint, extending from one-third to one-half of the circumference of the leg, and through the deep [ascia and periosteum of the tibia. Longitudinal incisions a r e made medially and laterally from the extremities of the first incision to the region low down in the leg, avoiding any areas of gangrene or infection. These a r e joined posteriorly, dividing the tendo Achillis (Figure I, l e f t ) . T h e flap, including the gastrocnemius and soleus muscles and overlying skin, is raised. T h e anterior compartment muscles a r e divided antl the fibula divided proximally with a Gigli saw, care being taken to protect the anterior skin. T h e tibia is divided with an anterior bevel starting below tlie level of the anterior skin incision, the bone end projecting ahoiit two centimetres below this le\-el. T h e deep posterior muscles a r e divided, completing the amputation (Figure I , centre left). Major vessels a r e ligated a i t h ahsorbable suture material as they are cut, and nerves a r e divided a s high as possible. T h e posterior flap is then thinned, removing most of the soleus muscles, and hremostasis is achieved. Care must be taken not to separate tlie :kin from the muscle of the flap. T h e muscle and deep fascia a r e divided a t a n appropriate level, and tliis layer is sutured to the anterior deep fascia and periosteum of the tibia with I/O llexon, placing a Penrose drain deep to this layer (Figure I, centre right). T h e posterior skin is then divided antl sutnred to the anterior skin edges (Figure I , right).
1;ic;un~ I : (left) skin incision and level of bone section; (left centre) posterior flap inclctding gastrocnemius and soleus (right centre) fascia of posterior flap sutured to periosteum and anterior tibia1 fascia ; right) completed amputation.
302
Ausr., N.Z. J. SURG., VOL.4j -NO. 3, AUGUST, 1975
BEI,O\V-I(NEE
AMPUTATION
Scalloping a t the suture line is usual and is quite acceptable. No attempt is made to correct “dog ears”. The dressings a r e taken down two days a f t e r operation, and the drain is removed. Sutures a r e left in situ for a t least three weeks. Mobilization of the patient is commenced as soon as his condition will allow. Physiotherapy is commenced on the third postoperative day. Care is taken t o prevent flexion deformities of both hip and knee. W e have not used any immediate prostheses in this series. The healed amputation is shown in Figure 2.
FIGURE 2 : (upper) photograph of healed amputation stump in extension ; (lower) photograph of healed, ,flexed amputation stump, showing mobility of the anterior scar over the bone.
RESULTS Mortality.-Five patients died within two weeks of operation, representing an immediate mortality of 16%. One of these developed gas gangrene in an ischzmic below-knee stump and died despite re-amputation above the knee. Rate of Healing.-Of 28 amputations following which the patient survived, primary healing occurred in 19, and delayed healing in six others. I n three of the latter group, operative revision with shortening of the tibia was required to achieve healing, while the other three required reamputation above the knee. AUST.N.Z. J. SURG., VOL.45 -NO. 3, AUGUST,1975
KING ET
ALII
DISCUSSION A satisfactory rate of healing can be achieved by this technique. Even if primary healing does not occur, delayed healing niay be expected because the suture line of the amputation does not overlie and hecome adherent to the sectioned end of the hone. This occurred in three patients. I n three other patients, in whoin infection was present, shortening of the tibia was necessary to achieve healing. I n all patients who required reampiitation, dead muscle was present at the primary amputation and although this was excised as completely as possible, nevertheless one of these patients died of gas gangrene. W e would now recommend above-knee amputation in any patient in whom the viability of muscle is in douht at the level of tihial section. Any major limb amputation carries a significant mortality (Lim et alii, 1967, 16%) ; (Ham et alii, 1964, 24%). This was certainly the case in our series. However, we believe that this amputation carries no more risk than other levels of amputation, and indeed, may be safer than an above-knee .amputation. The healing rate of 25 of 28 patients, or 89%, is encouraging, although the series is small. This rate is in keeping with other reported series such as those of Condon and Jordan I970), 81%; Lim et dii (1967)~ 83% ; Kendrick (1956), 95% ; for below-knee amputations. Martin et alii (1967) recorded a healing rate of 91% after Gritti-Stokes amputations. CONCLUSIONS Satisfactory healing can be achieved with a below-knee amputation in most severely ischzmic limbs. The elimination of an anterior flap with construction of a long myoplastic posterior flap and the use of a non-traumatic technique allows most below-knee amputations to heal. The healed stump is well padded and suitable for the fitting of a prosthesis. If dead muscle is present at the level of amputation, an above-knee amputation should be performed rather than an attempt to excise the muscles at a more proximal level. ACKKOWLEXEMENT W e should like to thank Mr J. Freidin for his help with the illustrations. 303
(ESOP LIAGI’AL
REDUPLICATION CYST
REFERENCES BURGESS, E. and ROMANO, R. (1968), Clitzical Orthopedics and Related Research, 57 : 137. CONDON,R. and JORDAW, P. (I970), S w g . G y m . Obstet., 130: 641. HAM,J., MCKENZIE,D. and LOEEVENTHAL, J. (1964), AUST., N.Z. J. Sum, 34: 97. HOMANS, J. (1939), “Circulatory Diseases of the Extremities”, MacMillan Co., New York. HUNTER-CRAIG, I., VITALI, M. and ROIIINSON,K. (1970), Brit. J . Sztrg., 57: 62.
KITCITIE KENDRICK,R. (1956), Brit. J . Szng., 4:13. LIM, R., BLAISDELL,F., HALL,R., MOORE,W. and THOMAS, A. (1967), Surg. Gynec. Obstet. 125: 493. LITTLE, J. M. (1973), Med. I . Aust.,2 : 442. MCCOLLOUGH, N., SHEA,J., WARREN, W. and SARMIENTO, A. (rg71), “Current Problems in Surgery : T h e Dysvascular Amputee : Surgery and Rehabilitation”. Year Book Medical Publishers Inc., Chicago, ’October : 4. MARTIN,P., RENWICK,S. and THOMAS,E. (1967), Brit. med. J., 3: 837.
Esophageal Reduplication Cyst JAMES
D. KITCHIE
St James Hospital, Balhanz, London A case of reduplication cyst o f the mo@hagus lined by partly ciliated epithelium i s presented. The cetiology, clinical presentation and treatment are discussed.
ESOPIIAGEAL reduplication cysts are very rare (Morson and Dawson, 1972). Gross (1953) laid down three a&eria for their recognition. These are that the cyst must be attached to the alimentary tract, that it must be lined by mucous membrane similar to that of some part of the alimentary tract, and that it must possess a smooth muscle coat. The ztiology of esophageal cysts is obscure. They are usually lined by gastric epithelium. They may be asymptomatic, or may present with dysphagia. Pain, hamorrhage and dyspima are less common modes of presentation. Once the c i s t has been diagnosed, its surgical removal is advised because of the high complication rate (Barlow, 1937). This can be accomplished by a thoracotomy, when the cyst can usually be shelled out in toto without opening the esophageal mucosa. rllxTlpAl D~~~~~ L L I L Y I L A L l.\LLUKU
A ~z-year-old Iranian Presented on December J972, with a three-year history of Pro€Tessive dYsphagia. At that time he was having difficulty in swallowing solids. ‘l%ere was no complaint Of Reprints : 16 Bondi Road, Bondi Junction, N.S.W. 2022.
304
regurgitation, weight loss, heartburn or indigestion. H e was healthy ,and well nourished, with no abnormal physical . signs. X-ray examination following a barium swallow had been performed in Iran. This showed a clearly outlined ovoid filling defect in the barium-filled esophagus a t the level of the fourth and fifth dorsal vertebrz (Figure ,I). Fibre-esophagoscopy was performed the same day under general anaesthesia. A submucosal lesion extending from zg to 34cm from the teeth, situated anteriorly and to the right, was seen. Transverse bridging folds were noted, a feature which is characteristic of a submucosal lesion. No biopsies were carried out. A right thoracotomy was performed on Decernher 27, 1972. A smooth tumour, approximately five centimetres in diameter, was seen lying beneath the muscle coat a t the junction of the middle and lower thirds of the esophagus. An ellipse of muscle over the tumour was excised, and dissection of the lesion was commenced. During dissection a cystic space in the lesion was opened and 2oml of greenish mucoid material escaped. The interior of the cyst was explored, but no communication was found with the esophagus. Dissection was continued and the cyst was removed. The most difficult ooint of the dissection was in the area where the mucosa of the cyst was adherent to the mucosa of the esophagus. They were separated by gauze dissection, without opening the esophageal mucosa. The muscle coat was reconstructed with a continuous catgut stitch, and the chest was closed with underwater seal drainage. X-ray examination following a Gastrografin swallow on the third postoperative day showed no leakage AUST., N.Z. J. SURC.,VOL.45 -NO.
3, AUGUST,1975
KING ET
toniy was not used as a primary procedure, but as a secondary procedure in two patients, both of whom will probably have further surgery.
REFERENCES
CASEY, B. H., HAMILTON, H. W. and BOBECHKE, W. P. (1972), J. Bone J t Surg., 54B : 607. DUNN, D. M. (1964), J. Bone J t Surg., 4 6 ~ 621. :
ALII
FERGUSON, A. B. and HAWORTH, M. B. (rg31), J. A m e r . med. Ass., 97: 1867. HUTCHINS, W. C. (1971), in “Campbell’s Operative Orthopzdics”, 5th edition, 2 : 1064. IMHAUSER, C. (1960), “Reconstruction Surgery and Traumatology”, S. Karger, Basel, 5 : 203 JERRE, T. (1960)~ Acts orthofi. scan& SUPPI.: 6. WILSON, P. D., JACOBS, B. and SCHECTER, L. (1965), J . Bone J t Surg,, 47-4: 1129.
Below- Knee Amputation in Peripheral Arterial Disease BARRYKING, RICHARDMCINTYREA N D KENNETHMYERS Vascular Consultative Service, Prince Henry’s Hospital, Melbourne A below-knee amputation will heal in m o s t patients w i t h atherosclerotic peripheral arterial disease, using no anterior flap and a long posterior myoplastic flap. T h e technique used b y the authors is presented in detail, w i t h their experience in 32 cases.
DESPITErecent advances in vascular reconstructive surgery, many patients with peripheral arterial disease still require amputation of the leg. I n a recent review from the Royal Prince Alfred Hospital, Sydney (Little, 1()73), it was shown that about the same number of patients come to amputation each year as have arterial reconstruction. It is difficult for the vascular surgeon to approach amputation with the same enthusiasm that he has for reconstructive surgery. Understandably, it may be thought of in terms of failure and something to be expedited and dismissed. However, for the patient, amputation should be a positive beginning to rehabilitation from a crippling and psychologically devastating disease. It can mean the beginning of renewed independence, mobility and freedom from pain. Until recently most surgeons believed that amputal :,in for peripheral arterial disease should be performed above the knee because a below-knee amputation was unlikely to heal. In 1939 Homans stated that “amputation below Reprints: Mr Barry King, 24 Collins St, Melbourne, Victoria 3000.
AUST. N.Z. J. SURG., VOL.45 -No. C
3, AUGUST,1975
the knee’can almost never be expected to offer a healthy stump”. I n recent years, however, several authors have shown that good healing rates can be achieved with below-knee amputations in peripheral arterial disease (Kendrick, 1956; Lim et alii, 1967; Condon and Jordan, 1970; Hunter-Craig et alii, 1970). Little (1973) reported that two-thirds of amputations performed at the Royal Prince Alfred Hospital, Sydney, between 1967 and 1971 were below-knee amputations, compared with one-sixth before that period. The advantages of below-knee amputations are great. Retention of the knee joint allows better proprioception, which increases the ease and likelihood of the patient learning to use a prosthesis, even in the very old. Even if the patient cannot learn to use a prosthesis, he finds it far easier to manceuvre himself in bed and get in and out of a wheelchair. Walking with a below-knee prosthesis requires far less energy expenditure than with an aboveknee prosthesis ( McCollough et alii, 1971) . These advantages of a below-knee amputation are doubly important in view of the high risk of eventual bilateral amputation. 301
B~:Lo\v-KNEI~ AMPUTATION If the patient is to benefit from the advantages of below-knee amputation, the surgeon must be able to offer a satisfactory healing rate antl a mobile, painless, tactile end-organ with good proprioception. W e believe that this can best be achieved by a technique similar to that described by Burgess and Romano (1968).
CLINICAL DETAILS I n this series, 32 patients underwent belowknee amputation for occlusive peripheral arterial disease causing gangrene. Their ages ranged from 47 to 88 years, with an average age of 70. There were 20 men and 12 women, and 13 were diabetic. Amputation followed failed arterial reconstruction in 23 legs. One patient had bilateral below-knee amputation. Below-knee amputation with this technique was carried out in all cases requiring amputation unless there was a specific contraindication. Such contraindications were rheumatoid arthritis of the knee and extensive ulceration of the lower leg rendering it impossible to design adequate skin flaps. I n all, five aboveknee amputations were performed in this period.
OPERATIVE TECHNIQUE The principles of the technique are to eliiniiiate an anterior flap because of its poor blood supply, and to preserve the blood supply
KINGET
ALIX
to the skin of the posterior flap which conies from vessels in the underlying muscle. The long posterior niyoplastic flap is sutured to the anterior skin proximal to the level of bone section, to avoid adherence of scar to bone. T h e leg is prepared in the usual manner, with the foot excluded from the operative field by a plastic foot bag tied a t the ankle. A n anterior transverse o r concave incision is made 1 2 to 15 cm helow the knee joint, extending from one-third to one-half of the circumference of the leg, and through the deep [ascia and periosteum of the tibia. Longitudinal incisions a r e made medially and laterally from the extremities of the first incision to the region low down in the leg, avoiding any areas of gangrene or infection. These a r e joined posteriorly, dividing the tendo Achillis (Figure I, l e f t ) . T h e flap, including the gastrocnemius and soleus muscles and overlying skin, is raised. T h e anterior compartment muscles a r e divided antl the fibula divided proximally with a Gigli saw, care being taken to protect the anterior skin. T h e tibia is divided with an anterior bevel starting below tlie level of the anterior skin incision, the bone end projecting ahoiit two centimetres below this le\-el. T h e deep posterior muscles a r e divided, completing the amputation (Figure I , centre left). Major vessels a r e ligated a i t h ahsorbable suture material as they are cut, and nerves a r e divided a s high as possible. T h e posterior flap is then thinned, removing most of the soleus muscles, and hremostasis is achieved. Care must be taken not to separate tlie :kin from the muscle of the flap. T h e muscle and deep fascia a r e divided a t a n appropriate level, and tliis layer is sutured to the anterior deep fascia and periosteum of the tibia with I/O llexon, placing a Penrose drain deep to this layer (Figure I, centre right). T h e posterior skin is then divided antl sutnred to the anterior skin edges (Figure I , right).
1;ic;un~ I : (left) skin incision and level of bone section; (left centre) posterior flap inclctding gastrocnemius and soleus (right centre) fascia of posterior flap sutured to periosteum and anterior tibia1 fascia ; right) completed amputation.
302
Ausr., N.Z. J. SURG., VOL.4j -NO. 3, AUGUST, 1975
BEI,O\V-I(NEE
AMPUTATION
Scalloping a t the suture line is usual and is quite acceptable. No attempt is made to correct “dog ears”. The dressings a r e taken down two days a f t e r operation, and the drain is removed. Sutures a r e left in situ for a t least three weeks. Mobilization of the patient is commenced as soon as his condition will allow. Physiotherapy is commenced on the third postoperative day. Care is taken t o prevent flexion deformities of both hip and knee. W e have not used any immediate prostheses in this series. The healed amputation is shown in Figure 2.
FIGURE 2 : (upper) photograph of healed amputation stump in extension ; (lower) photograph of healed, ,flexed amputation stump, showing mobility of the anterior scar over the bone.
RESULTS Mortality.-Five patients died within two weeks of operation, representing an immediate mortality of 16%. One of these developed gas gangrene in an ischzmic below-knee stump and died despite re-amputation above the knee. Rate of Healing.-Of 28 amputations following which the patient survived, primary healing occurred in 19, and delayed healing in six others. I n three of the latter group, operative revision with shortening of the tibia was required to achieve healing, while the other three required reamputation above the knee. AUST.N.Z. J. SURG., VOL.45 -NO. 3, AUGUST,1975
KING ET
ALII
DISCUSSION A satisfactory rate of healing can be achieved by this technique. Even if primary healing does not occur, delayed healing niay be expected because the suture line of the amputation does not overlie and hecome adherent to the sectioned end of the hone. This occurred in three patients. I n three other patients, in whoin infection was present, shortening of the tibia was necessary to achieve healing. I n all patients who required reampiitation, dead muscle was present at the primary amputation and although this was excised as completely as possible, nevertheless one of these patients died of gas gangrene. W e would now recommend above-knee amputation in any patient in whom the viability of muscle is in douht at the level of tihial section. Any major limb amputation carries a significant mortality (Lim et alii, 1967, 16%) ; (Ham et alii, 1964, 24%). This was certainly the case in our series. However, we believe that this amputation carries no more risk than other levels of amputation, and indeed, may be safer than an above-knee .amputation. The healing rate of 25 of 28 patients, or 89%, is encouraging, although the series is small. This rate is in keeping with other reported series such as those of Condon and Jordan I970), 81%; Lim et dii (1967)~ 83% ; Kendrick (1956), 95% ; for below-knee amputations. Martin et alii (1967) recorded a healing rate of 91% after Gritti-Stokes amputations. CONCLUSIONS Satisfactory healing can be achieved with a below-knee amputation in most severely ischzmic limbs. The elimination of an anterior flap with construction of a long myoplastic posterior flap and the use of a non-traumatic technique allows most below-knee amputations to heal. The healed stump is well padded and suitable for the fitting of a prosthesis. If dead muscle is present at the level of amputation, an above-knee amputation should be performed rather than an attempt to excise the muscles at a more proximal level. ACKKOWLEXEMENT W e should like to thank Mr J. Freidin for his help with the illustrations. 303
(ESOP LIAGI’AL
REDUPLICATION CYST
REFERENCES BURGESS, E. and ROMANO, R. (1968), Clitzical Orthopedics and Related Research, 57 : 137. CONDON,R. and JORDAW, P. (I970), S w g . G y m . Obstet., 130: 641. HAM,J., MCKENZIE,D. and LOEEVENTHAL, J. (1964), AUST., N.Z. J. Sum, 34: 97. HOMANS, J. (1939), “Circulatory Diseases of the Extremities”, MacMillan Co., New York. HUNTER-CRAIG, I., VITALI, M. and ROIIINSON,K. (1970), Brit. J . Sztrg., 57: 62.
KITCITIE KENDRICK,R. (1956), Brit. J . Szng., 4:13. LIM, R., BLAISDELL,F., HALL,R., MOORE,W. and THOMAS, A. (1967), Surg. Gynec. Obstet. 125: 493. LITTLE, J. M. (1973), Med. I . Aust.,2 : 442. MCCOLLOUGH, N., SHEA,J., WARREN, W. and SARMIENTO, A. (rg71), “Current Problems in Surgery : T h e Dysvascular Amputee : Surgery and Rehabilitation”. Year Book Medical Publishers Inc., Chicago, ’October : 4. MARTIN,P., RENWICK,S. and THOMAS,E. (1967), Brit. med. J., 3: 837.
Esophageal Reduplication Cyst JAMES
D. KITCHIE
St James Hospital, Balhanz, London A case of reduplication cyst o f the mo@hagus lined by partly ciliated epithelium i s presented. The cetiology, clinical presentation and treatment are discussed.
ESOPIIAGEAL reduplication cysts are very rare (Morson and Dawson, 1972). Gross (1953) laid down three a&eria for their recognition. These are that the cyst must be attached to the alimentary tract, that it must be lined by mucous membrane similar to that of some part of the alimentary tract, and that it must possess a smooth muscle coat. The ztiology of esophageal cysts is obscure. They are usually lined by gastric epithelium. They may be asymptomatic, or may present with dysphagia. Pain, hamorrhage and dyspima are less common modes of presentation. Once the c i s t has been diagnosed, its surgical removal is advised because of the high complication rate (Barlow, 1937). This can be accomplished by a thoracotomy, when the cyst can usually be shelled out in toto without opening the esophageal mucosa. rllxTlpAl D~~~~~ L L I L Y I L A L l.\LLUKU
A ~z-year-old Iranian Presented on December J972, with a three-year history of Pro€Tessive dYsphagia. At that time he was having difficulty in swallowing solids. ‘l%ere was no complaint Of Reprints : 16 Bondi Road, Bondi Junction, N.S.W. 2022.
304
regurgitation, weight loss, heartburn or indigestion. H e was healthy ,and well nourished, with no abnormal physical . signs. X-ray examination following a barium swallow had been performed in Iran. This showed a clearly outlined ovoid filling defect in the barium-filled esophagus a t the level of the fourth and fifth dorsal vertebrz (Figure ,I). Fibre-esophagoscopy was performed the same day under general anaesthesia. A submucosal lesion extending from zg to 34cm from the teeth, situated anteriorly and to the right, was seen. Transverse bridging folds were noted, a feature which is characteristic of a submucosal lesion. No biopsies were carried out. A right thoracotomy was performed on Decernher 27, 1972. A smooth tumour, approximately five centimetres in diameter, was seen lying beneath the muscle coat a t the junction of the middle and lower thirds of the esophagus. An ellipse of muscle over the tumour was excised, and dissection of the lesion was commenced. During dissection a cystic space in the lesion was opened and 2oml of greenish mucoid material escaped. The interior of the cyst was explored, but no communication was found with the esophagus. Dissection was continued and the cyst was removed. The most difficult ooint of the dissection was in the area where the mucosa of the cyst was adherent to the mucosa of the esophagus. They were separated by gauze dissection, without opening the esophageal mucosa. The muscle coat was reconstructed with a continuous catgut stitch, and the chest was closed with underwater seal drainage. X-ray examination following a Gastrografin swallow on the third postoperative day showed no leakage AUST., N.Z. J. SURC.,VOL.45 -NO.
3, AUGUST,1975
