Conservative Surgical Treatment of Reflux Esophagitis and Esophageal Stricture J. LYNWOOD HERRINGTON, JR., M.D., ROSS S. WRIGHT M.D., WILLIAM H. EDWARDS, M.D., JOHN L. SAWYERS, M.D.
During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intraoperative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.
T HE DEVELOPMENT of an esophageal stricture secondary to reflux esophagitis is usually the result of failure of medical treatment or patient neglect and may be preventable. It is an unpredictable phenomenon and may present either early or late in the symptomatic patient. The stricture may be short and annular or longitudinal and ascending. In the former the inflammatory reaction is usually confined to the esophageal mucosa and submucosa, and the stricture is located at or near the gastroesophageal junction. In the latter there is usually extensive transmural involvement which may spread to the periesophageal and mediastinal structures. Such strictures may extend proximally to the level of the aortic arch, and the esophagus below the stricture may or may not be lined with columnar epithelium. 1,17.18 Controversy continues to exist regarding the surgical management of the reflux stricture and a wide range of operative procedures has been suggested. Some au-
thorities feel that operations of considerable magnitude as esophageal resection with jejunal or colonic interposiPresented at the Annual Meeting of the Southern Surgical Associa-
tion, December 9-11, 1974, Boca Raton, Florida.
From The Department of Surgery, Vanderbilt University Medical Center and the Surgical Services of St. Thomas Hospital, Vanderbilt University Hospital and The Metropolitan General Hospital Nashville, Tennessee
tion or esophagogastroplasties of the Thal-Nissen, Collis, or Heimlich types are necessary to achieve success. Valvular esophagogastrostomy and stricture excision combined with vagotomy-antrectomy with either Roux-en-Y diversion or Henley loop construction have been employed. Transgastric excision of annular strictures combined with an antireflux procedure has also been reported with good results. l 8'9"" 114"19,23,25,30,38,41,43 The preoperative assessment of an esophageal stricture using barium swallow, cin6fluoroscopy, endoscopy with biopsy, and attempts at dilatation may at times be misleading. Actual stricture length and degree of esophageal fixation and fibrosis may not always be accurately determined by such studies. Therefore to chose a particular surgical procedure on the basis of such clinical information would appear unsound. Hayward12'13 of Australia was perhaps the first to emphasize that selection of operation should be made at the time of surgery after the extent and degree of the stricture have been thoroughly ascertained. Operative findings correlated poorly with preoperative evaluation in his experience. Hayward found that many tough, fibrous strictures in patients with persistent dysphagia could be treated by operative dilatation accompanied by an antireflux procedure, and seldom was resectional surgery necessary. In this country Hill15"16 has pursued the simplified approach and has convincingly shown that advanced strictures respond to this method of therapy. Moran 21 likewise stresses that the exact extent and degree of an esophageal stricture can only be determined at operation and many advanced strictures of long standing can be- successfully
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17 Patients
menme
Age Range: 46 -90 yrs Average Age: 63 yrs
DURATION OF SYMPTOMS: 18mos-30yrs FIG. 1. Reflux Esophageal Stricture.
dilated intraoperatively and a satisfactory result obtained if associated reflux is corrected. Brindley,4 Paulson23'24 and Boyd3 have each noted satisfactory results with this method. The purpose of this communication is to cite a recent three-year experience in which this conservative surgical approach was used in the management of a small group of 17 consecutive patients with advanced reflux stricture. Material
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Method The conservative approach to the treatment of reflux stricture may not be applicable to all cases, therefore preoperative discussions with the patient, the operating team, and nursing personnel give consideration to the possible performance of a more radical procedure should the stricture prove unyielding to intra-operative dilatation. The abdomen is first opened and after general exploration attention is directed to the left upper abdominal quadrant. The suspensary ligament of the left hepatic lobe is divided and the lobe retracted to the right. The peritoneal and fibrous structures about the proximal stomach and distal esophagus are freed next. The cephalad portion of the gastrohepatic omentum is transected, and the greater gastric curve mobilized by dividing the uppermost vasa brevia vessels. If the stricture is of the longitudinal type or the annular variety that proved unyielding on preoperative assessment, a short transverse gastrotomy is performed on the anterior wall of the cardia just below the gastroesophageal junction and held open with Guy sutures. The gastroesophageal orifice is visualized and palpated digitally to determine the degree of stenosis present. With the fingers of the surgeon's left hand placed behind and around the proximal cardia and distal esophagus, the stenosed gastroesophageal aperture is gently dilated with graduated Hegar dilators. Simultaneously, a member of the operating team passes a rigid gastroscope via the oral route to the proximal limit of the stricture. Graded filiform dilators are then passed through the stricture followed by tapered Maloney dilators. A number 20F is used initially followed by graduated sizes up to a number 34 to 38F. The rigid gastroscope is removed as the larger Maloney dilators are
There were 9 men and 8 women among the group of 17 patients comprising the clinical study. The ages ranged from 46 to 90 years with the average age being 63 years. Symptoms suggesting reflux esophagitis were present from 18 months up to 30 years. Two patients had undergone unsuccessful surgical attempts for correction of gastroesophageal reflux (Fig. 1). Severe and persistent dysphagia was experienced by each patient. Eight patients had complete or near complete obstruction to liquid intake, and three patients had difficulty swallowing their saliva. The remaining patients could not 'partake of solid food. The preoperative workup included barium examination of the esophagus and upper gastrointestinal tract when possible, cinefluoroscopy, and esophagoscopy with biopsy. The presence of carcinoma was ruled out in each of the cases. Barium enema examination was done to assess colonic length and to exclude colonic disease should a colon interposition procedure prove necessary. In 10 cases the stricture was of the longitudinal type, and in 7 cases a short distal annular stricture existed (Fig. 2). ANNULAR In some of the latter cases preoperative dilatation was LONG ITUDINAL attempted but proved unsuccessful. Dilatation was 7 cases 10 cases primarily carried out as an integral part of the operative FIG. 2. Types of esophageal strictures encountered among the 17 patients. procedure in all cases.
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FIG. 3. Sketch depicting simultaneous antegrade and retrograde dilatation of a longitudinal esophageal stricture.
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small sliding esophageal hiatus hernia with gastroesophageal reflux. Esophagoscopy at the time showed evidence of esophagitis, but there was no stricture formation. She was treated with a bland diet, antacids and told to sleep with the head of her bed elevated. The patient followed these instructions for a few weeks, but did not improve and therefore discontinued medications as well as her physician's advice. During the next several weeks she noted progressive dysphagia and lost 30 pounds in weight. She experienced no melena or hematemesis. When seen at our institution a barium swallow re-
vealed a stricture of the lower esophagus and the barium
pill failed to progress through the strictured area. Endosintroduced. During this time the operator continues to dilate the distal limits of the stricture via the gastrotomy and the tapered dilators introduced from above will be seen to pass gradually through the length of the stricture. With the stricture now open larger Maloney dilators may be safely passed from above while the operator clearly visualizes the interior of the distal esophagus. With the left hand positioned around the esophagus he can determine the extent to pursue the dilatations from above (Fig. 3). After satisfactory dilatation the gastrotomy is closed and the attenuated defect in the right crural sling is approximated if the gastroesophageal junction lies below the diaphragm without tension. Should it prove difficult or impossible to bring the gastroesophageal junction below the diaphragmatic level, it is best to leave the crural aperture unapproximated with a small portion of gastric cardia displaced in the posterior mediastinum. In two of the present cases a small portion of the cardia was left above the level of the diaphragm. In two other cases the crural defect was small and the muscle fibers were purposely not approximated. Each of the 17 patients was found to have a sliding esophageal hiatal hernia. As the final important step an antireflux procedure is carried out. Fifteen patients underwent a Nissen fundoplication operation, one had a Hill posterior gastropexy, and a Belsey repair was used in one patient (Fig. 4). Two patients had an associated duodenal ulcer, and vagotomy and pyloroplasty were done. Eight patients among the group required simultaneous antegrade and retrograde intraoperative dilatation, whereas 9 patients underwent antegrade dilatation only.
copy showed a localized annular stricture 36 cm from the incisor teeth, and mucosal biopsy revealed no evidence of malignancy. Only the smallest Maloney tapered dilator (20F) could be passed through the strictured area with difficulty. At operation the gastroesophageal junction was freed up and a small sliding esophageal hiatal hernia was present. Esophageal dilatation was carried out via the oral route by a member of the operating team using graduated Maloney dilators, beginning with a 20F and gradually increasing to a 40F. During manipulation from above, the operator from below, with the fingers of his left hand around the distal esophagus, guided the graduated Maloney dilators through the stricture. The small defect in the right crural sling was repaired followed by a Nissen
fundoplication. During a 9 month followup the patient has remained asymptomatic. She has regained her lost weight, and postoperative esophageal dilatation has not been necessary. Several repeat barium swallows during this time reveal the lower esophagus to be essentially normal (Fig. 5). Endoscopy likewise reveals normal findings. Comment. Although this patient had been experiencing symptoms of gastroesophageal reflux for a number of years, she developed the annular stricture over a relatively short period of several weeks. It was not necessary to dilate the stricture through a gastrotomy incision as controlled dilatation by a member of the operating team
Illustrative Cases Case I M.H.: A 46-year-old woman was admitted to St. Thomas Hospital 3/20/74 with a 10-year history of upper abdominal discomfort, frequent eructations and 15 cases substernal burning. Four months before admission she FIG. 4. Types had been evaluated elsewhere and was told that she had a tients.
I case
I case
of antireflux procedures performed among the 17 pa-
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hiatus hernia and no evidence of malignancy was present. Preoperative esophageal dilatation was not performed. At laparotomy a moderate size sliding esophageal hiatus hernia existed. It was elected to first attempt dilaFIG. 5A. Case 1: Preoperatation of the esophageal stricture from above by a tive esophagram showing a distal annular esophageal member of the operating team. The 20F tapered Maloney stricture with the barium dilator was passed through the stricture and after careful pill trapped just above the strictured area. and meticulous manipulations additional graduated dilators up to a 38F were passed. The defect in the crural sling was approximated as the gastroesophageal junction could be brought below the diaphragmatic level without tension. A Nissen fundoplication was carried out and the gastroesophageal orifice was calibrated over a No. 38 working from above in conjunction with gudiance from Maloney dilator. The dilator was then removed and a nasogastric tube was passed into the stomach. A bilateral below proved successful. Case 2-J.F. A 62-year-old Negro man was admitted to truncal vagotomy and Weinberg type pyloroplasty were St. Thomas Hospital 11/6/73 with a 12 year history of performed for the channel ulcer (Fig. 7). Following the antireflux procedure the patient was reburning epigastric- pain, relieved somewhat by the intake of food, along with substernal distress and frequent reg- lieved of dysphagia and after a one year follow-up has no urgitation. During the past year he noted progressive symptoms of dysphagia and currently was unable to swallow solid food. Barium studies revealed a striking longitudinal narrowing of the distal esophagus and the presence of a moderate size sliding esophageal hiatus hernia. There was also a pronounced deformity of the distal pylorus and duodenal bulb consistent with the diagnosis of channel ulcer (Fig. 6). Esophagoscopy demonstrated marked narrowing of the esophagus above the level of the
FIG. SB. Postoperative barium study showing complete correction of the stricture. The deformity at the gastroesophageal junction depicts the Nissen fundoplication.
FIG. 6. Case 2: Preoperative barium esophagogastrointestinal study depicting a tight, longitudinal esophageal stricture with a moderate size sliding esophageal hiatus hernia. Also a rather marked deformity of the distal pyloric channel and duodenal bulb exist.
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Case 3-H.N. A 55-year-old man entered St. Thomas Hospital 4/5/73 with the complaint of severe dysphagia. For several months he had not been able to partake of solid foods. Five years prior he had undergone an Allison repair for a sliding esophageal hiatus hernia. The patient was relieved of symptoms until approximately one year prior to the present admission when he experienced difficulty swallowing. There had been a 15 pound weight loss. Upper gastrointestinal study in the early postopera- Esophagram revealed an advanced distal longitudinal tive period shows correction of stricture along with a recurrent hiatus hernia. the esophageal stricture and Esophagoscopy showed the presence of the stricture and hiatus hernia. The gastroesophageal junction has been calibrated a biopsy demonstrated no evidence of malignancy. Preoperative attempt at esophageal dilatation performed over a No. 38 Maloney dilator and an antireflux operation per- elsewhere was unsuccessful. Further dilatation was not formed. pursued at our institution. At operation the recurrent hiatal hernia was reduced with some difficulty, and through an anterior gastrotomy, the gastroesophageal junction, which was extremely stenosed, was dilated with graduated Hegar dilators. Simultaneously, a member of the operative team from above dilated the proximal aspect of the stricture, employing graduated filiform dilators passed through the rigid gastroscope. The scope was withdrawn and graduated tapered Maloney dilators, up to a 38F, were symptoms referable to the gastro-intestinal tract. A re- introduced through the stricture. A No. 15 Hegar dilator cent barium study of the esophagus and stomach reveals was finally passed retrogradely, thus opening the entire only slight narrowing at the area of the previous stricture strictured area. The crural sling was next approximated and endoscopic examination shows no evidence of and a Nissen fundoplication was performed over a 38F esophagitis. The ulceration in the duodenum remains Maloney dilator. healed (Fig. 8). The patient has now been followed 20 months, has Comment. Although this patient had a tight longitudi- gained 30 pounds and experiences no difficulty swallownal stricture above the sliding esophageal hiatal hernia it ing. A recent barium study of the upper gastrointestinal was possible to dilate the stricture adequately from above tract reveals no evidence of reflux and the diameter of the and retrograde dilatation through a gastrotomy was not distal esophagus is within normal limits (Fig. 9). necessary. Comment. Combined antegrade and retrograde dilataFIG. 7. Case 2:
FIG.
8.
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2:
Barium
study one year postoperative reveals no evidence of recurrent stricture or her-
nia formation. The patient has been relieved of all symptoms.
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FIG. 9. Case 3: (Left) Barium swallow showing the advanced, longitudinal stricture with associated hiatus hernia. (Right) Upper gastrointestinal barium study 20 months postoperative reveals no evidence of recurrent stricture formation and no hiatus hernia.
4a .
tion of the strictured esophagus proved necessary in this she was only able to swallow liquids and experienced a 20 case. In our opinion neither approach alone would have pound weight loss. She had noted heartburn and epigassufficed in alleviating the esophageal stenosis. Prepara- tric fullness over the past 12 years, and 5 years before tions had been made prior to operation to perform a more admission an upper gastrointestinal study revealed the radical procedure such as colon interposition had com- presence of a sliding esophageal hiatal hernia. Aside from bined efforts at dilatation been unsuccessful. the occasional use of Donnatal and Valium she had had Case 4-M.P. A 68-year-old woman was admitted to St. no specific treatment. Thomas Hospital 10/1/73 with a one year history of proBarium swallow revealed a striking, tapering stenosis gressive difficulty in swallowing. Within recent months of the distal esophagus with the lumen measuring 2 mm, at its narrowest point. Distal to the stenosed area a fine trickle of barium outlined a small hiatus hernia (Fig. 10). Esophageal biopsy showed no evidence of tumor. At operation, through a midline abdominal incision, a high gastrotomy opening was made and retrograde dilatation of the stricture was carried out using graduated Hegar dilators. Simultaneously, the stricture was dilated from above using filiform dilators followed by graduated tapered Maloney bougies. The esophagogastric junction was brought below the diaphragmatic level without tension, and the right crural sling was approximated. A Nissen fundoplication was performed over a 36F Maloney dilator. The patient has been carefully followed for 14 months and has not required subsequent dilatation. Symptoms have been relieved and a recent barium study of the upper gastrointestinal tract reveals the esophagus to be entirely normal (Fig. 11). Comment. This patient presented with an extremely tight and fibrotic stricture of the distal esophagus which was longitudinal in type. From a study of the preoperative esophagram some doubt was raised as to whether this stricture could be dilated intraoperatively. However, FIG. 10. Case 4: Preoperative barium swallow demonstrating a tapering the combined approach adequate dilatation was using stenosis of the distal esophagus with an esophageal lumen measuring 2 mms. performed, followed by an antireflux procedure.
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FIG. 11. Case 4: (Left) Barium swallow on the 7th postoperative day reveals some increase in the diameter of the esophageal lumen as compared to the preoperative study. (Right) Upper gastrointestinal contrast study 14 months postoperative reveals the esophagus and esophagogastric junction to be perfectly normal. The patient was relieved of all symptoms during the early postoperative period and did not require additional dilatation.
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posely not reapproximated. The operator was unable to displace the lower few centimeters of the esophagus below the diaphragm without producing tension on the former structure. Therefore a portion of the fundoplication was left above the diaphragmatic level, and the edge of the diaphragm was sutured loosely to the mid aspect of the fundoplication. Postoperatively the patient did well but necessitated dilatation on two occasions for mild upper abdominal discomfort. Esophagoscopy shows no evidence of reflux or esophagitis and a barium swallow 6 months postop revealed improvement over the early postoperative study with only slight narrowing at the former stricture site. The esophageal lumen, however, appears adequate. The Nissen fundoplication may be seen lying partially in the posterior mediastinum and it functions adequately in preventing reflux (Fig. 13). Comment. This annular stricture. could undoubtedly have been adequately excised through a transgastric approach. However, dilatations from above proved adequate and obviated the need for anterior gastrotomy. Some, perhaps, might have elected to treat this stricture by the more complicated method of Thal. Case 6-U.B. A 68-year-old woman was admitted to the Metropolitan General Hospital 10/10/71 with a 30 pound weight loss and progressive dysphagia over a period of 6 months. Recently she had experienced difficulty in swallowing liquids. Past history showed that for at least 10
Case 5-A.H. A 49-year-old man was admitted to St. Thomas Hospital 6/25/74 with a 3 year history of upper abdominal discomfort, substernal burning and frequent regurgitation. He had been diagnosed elsewhere as having a sliding esophageal hiatus hernia and appropriate medical treatment was instituted. However, symptoms progressed in severity and he began to experience dysphagia. He could not swallow solids and it was necessary for his wife to puree his food. Barium study revealed a tight, annular, distal esophageal stricture and just below the stricture was a moderate size sliding esophageal hiatus hernia (Fig. 12). Biopsy ruled out the presence of carcinoma and all other findings were normal. Through an abdominal approach the esophageal hiatal hernia was freed up and the distal esophagus exposed. With the fingers of the operator's left hand surrounding the esophagus, a member of the operating team from above passed the graded Maloney dilators through the stricture site beginning with a No. 20F and progressing to a 44F. A Nissen fundoplication was then performed over FIG. 12. Case 5: Preoperative barium study shows a tight, annular, a No. 38F Maloney dilator and the crural sling was pur- distal esophageal stricture with a sliding esophageal hiatus hernia.
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FIG. 13. Case 5: Barium study 6 months postoperative reveals only slight narrowing at the former stricture site. The Nissen fundoplication may be seen lying partially in the posterior mediastinum. This patient required dilatation on two occasions during the early postoperative period, after which he has been relieved of all symptoms.
years she had noted heartburn, upper abdominal fullness and substernal distress. A hiatus hernia was diagnosed at that time but the patient had not followed medical therapy. Barium examination of the esophagus revealed a tight, longitudinal stricture, and distal to the narrow barium column a small hiatus hernia was visualized (Fig. 14). Biopsy taken from the proximal limit of the stricture showed no evidence of malignancy and preoperative dilatation was not attempted. At operation, employing a left thoracotomy, the longitudinal stricture was dilated from above while the operator controlled the dilatations with his fingers about the mobilized esophagus. A Belsey Mark IV antireflux procedure was then carried out. The patient required several dilatations during the first few post-orerative
months and the stricture was gradually dilated up to a Maloney 44F. An upper gastrointestinal study 3 years postoperative revealed the esophagus to be normal (Fig. 15). No reflux can be demonstrated on endoscopy and no recurrent hiatus hernia is noted. The patient does experience mild to moderate upper abdominal burning pain which is controlled with medications. Comment. This case represents a tight, longitudinal stricture of the distal one-third of the esophagus which some surgeons prefer to treat by an interposition procedure or esophagogastroplasty. A less formidable procedure, however, sufficed to alleviate this patient's dysphagia completely. Case 7-J.R. A 69-year-old Negro man was admitted to St. Thomas Hospital 10/5/72 with a 30 year history of
I
L,.As FIG. 14. Case 6: Preoperative esophagram showing an advanced, longitudinal stricture of the lower esophagus.
FIG. 15. Case 6: Gastrointestinal study 3 years postoperative reveals the caliber of the esophageal lumen to be normal. The Belsey Mark IV antireflux procedure continues to function adequately.
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anterior gastrotomy with graded Hegar dilators and from above by first employing filiform catheters, followed by graduated tapered Maloney dilators up to a No. 34F. The crural sling was approximated and a posterior gastropexy as described by Hill was used to correct reflux. Postoperatively the patient did well and was able to progress to soft food. Dilatations were continued for several months and he was able to eat a soft diet but certain foods were poorly tolerated. Adequate nutrition was maintained and the patient was satisfied with the clinical result. An x-ray 18 months after operation showed mild dilatation proximal to the original stricture but the stenosed area had opened up considerably and an ample lumen was present (Fig. 17). The patient was followed for a period of two and one half years at which time he died of a cerebrovascular accident. Comment. This elderly gentleman presented with a far-advanced fibrotic longitudinal stricture and preoperative opinions from several authoritative consultants were that a radical approach to the stricture would be necessary. However, combined dilatation from above and below along with the antireflux procedure produced an acceptable result. Case 8-V.B. A 53-year-old woman was admitted to Metropolitan City Hospital 5/25/72 with a 6 year history of upper abdominal fullness, heartburn and regurgitation. FIG. 16. Case 7: Barium study showing a far-advanced longitudinal stricture with dilatation of the esophagus proximal to the stricture.
upper abdominal fullness and substernal discomfort. For the past 12 weeks before admission he experienced progressive dysphagia and had difficulty swallowing liquids. He had lost 40 pounds in weight and experienced marked lassitude and fatigue. Upon admission the patient appeared acute and chronically ill and showed evidence of marked weight loss. He had difficulty swallowing his saliva. The hemogram was 10, albumin was 2.2 and total serum protein was 5.8. Extensive workup was done including an upper gastrointestinal study which showed dilatation of the proximal esophagus, and beginning 33 cm, from the incisor teeth there was an advanced fibrous stricture (Fig. 16). However, after several minutes of fluoroscopic observation, a trickle of barium was seen to pass through the strictured area. At endoscopy the proximal limit of the stricture was visualized and a biopsy showed no evidence of tumor. A No. 4 filiform catheter could not be introduced through the stricture. The patient was given adequate blood and colloid replacement and put on total parenteral hyperalimentation for a period of 3 weeks. During this time he gained 15 pounds and his general condition improved considerably. At operation the stricture was dilated retrogradely via
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FIG. 17. Case 7: Contrast study of the esophagus 18 months postoperative reveals minimal dilatation of the proximal esophagus, but the lumen through the previous strictured area appears adequate. Esophageal dilatations were necessary for several months postoperative, but this elderly patient was able to eat a soft diet without difficulty.
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561 markedly dilated with evidence of retained fluid. No peristaltic activity was present and esophageal emptying took place by increased hydrostatic pressure with the patient erect. Distal to the dilatation an advanced longitudinal stricture was noted (Fig. 18). Esophagoscopy confirmed the diagnosis of a pronounced esophageal stricture and biopsy at the proximal limit of the stricture showed no evidence of malignancy. *} After adequate preoperative preparation the stricture T was dilated using the combined approach followed by a Nissen fundoplication. Several dilatations were instituted for a few weeks postoperatively after which they were discontinued. During the ensuing months the patient gained 47 pounds and a barium swallow showed marked improvement. She has been seen at frequent intervals during the past two and one half years, has no dietary limitations, and is symptom-free. A recent esophagram reveals a slight narrow area in the distal esophagus but the lumen through this area measures almost one cm. (Fig. 19). Comment. This patient also presented with an advanced fibrotic stricture and one could not determine from preoperative assessment whether intraoperative dilatation would be possible. However, intraoperative combined dilatations followed by an anti-reflux operation FIG. 18. Case 8: Preoperative barium swallow shows marked dilatat proved effective in eliminating symptoms and restoring iton of the proximal esophagus with retained food and secretions. Dista the dilatation a striking longitudinal esophageal stricture is present. T hist the esophagus to near normal. Although slight narrowing patient had difficulty swallowing her saliva. of a segment of esophagus exists, it has caused the patient no symptoms over a two and one half year followup. During the past year she had experienced difficulty'in Case No. 9-L.R. A 90-year-old Caucasian man was swallowing and currently was only able to partake f a admitted to St. Thomas Hospital 10/3/71 with a history of liquid diet. dyspepsia dating back at least 40 years. He had been told An esophagram revealed the proximal esophagus to be that he had an esophageal hiatal hernia, but had never
FIG. 19. Case 8: (Left) An esophagram during the early postoperative period after 2 dilatations reveals only slight narrowing with longitudinal stricture. (Right) An
correction of the
esophagram 2 years postoperative reveals only slight esophageal narrowing and the patient has obtained an excellent result.
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preoperative preparation with total parenteral nutrition the patient was taken to surgery. Employing simultaneous antegrade and retrograde dilatation of the longitudinal stricture, a 30F Maloney dilator was finally passed into the stomach. The crural sling was approximated and a Nissen plication done. Postoperatively the patient was dilated with the smaller Maloney dilators and was able to swallow liquids and soft food. Following discharge dilation was done frequently during the first 6 months and monthly dilatations were continued to one year. At the end of this time a barium swallow showed marked narrowing of the distal one-third of the esophagus but surprisingly the patient had no difficulty eating soft foods (Fig. 21). He could not, however, tolerate solids. Weight gain took place and he remained in fairly good health until he died two and one half years postoperative, apparently from a myocardial infarction. Comment. This elderly man presented with a faradvanced esophageal stricture in which the lumen was all but completely occluded. Had this patient not been of advanced age and relatively free of associated constitutional disease a colonic orjejunal interposition procedure would have been performed. It is surprising however, that operative dilatation and correction of reflux were effective to a great degree in alleviating his total obstruction and allowing him to eat a restricted diet. Results and Followup Sixteen of the 17 patients survived operation and have been carefully followed. One patient, a 72-year-old man FIG. 20. Case 9: Complete esophageal obstruction resulting from benign reflux stricture. This 90-year-old patient could not swallow liquids and had difficulty swallowing his saliva.
been advised to follow a medical program. Eight years before admission he underwent a cholecystectomy and during the postoperative course a nasogastric tube was kept in place for several days. Following discharge from the hospital dyspepsia increased and he experienced rather severe substernal distress and regurgitation. He noted progressive difficulty swallowing solid foods and for the next several years consumed a soft diet. Several months before admission he noted difficulty swallowing liquids and for a few weeks prior to admission had difficulty swallowing his saliva. He lost about 40 pounds during this period and experienced marked weakness and fatigue. Upon admission the patient appeared chronically ill and the hemogram was 9.4. A barium swallow revealed FIG. 21. Case 9: Postoperative barium study after one year shows marked dilatation of the proximal exophagus and com- diminution in the caliber of the previously dilated proximal esophagus. plete obstruction was noted at the junction of the middle The strictured area still persists, but the esophageal lumen throughout and distal third (Fig. 20). Esophagoscopy confirmed the this area shows considerable improvement as compared to the of some persistent esophageal narrowing. presence of complete obstruction but no evidence of a preoperative state. In spite able to take a restricted diet, gained weight, this 90-year-old patient was tumor was noted. After an extensive workup and and was markedly improved.
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FIG. 22. Follow-up results for 16 patients. GOOD 25%(4) I Hositl Deoth in
IMPOVED 6%(1) Original 17 Patlmt
with pre-existing cardiac disease developed a cerebrovascular accident during the early postoperative period and expired. Two patients have since died of unrelated causes, each two and one-half years postoperative but are included in the followup. Each living patient has been observed at frequent intervals and esophagoscopy and barium contrast studies of the upper gastrointestinal tract have been part of the postoperative evaluation. Eleven patients have obtained an excellent clinical result, experience no upper abdominal discomfort, and have no dietary restrictions. Four patients are termed a good result since each experiences mild and intermittent abdominal discomfort. One of the 4 has subjective evidence of reflux but esophagoscopy shows no demonstrable reflux or esophageal mucosal changes. This patient had a Belsey repair as the antireflux procedure in contrast to most of the group who underwent a Nissen fundoplication. Another patient with a good result had undergone a prior operation for reflux and also had a leiomyoma removed from the esophagus. The third patient listed as a good result had almost complete esophageal occlusion prior to operation. The fourth patient, likewise, presented with a far-advanced longitudinal stricture. Following dilatation and correction of reflux he has tolerated soft foods well but certain solid foods cause mild upper abdominal distress. The 90-year-old man with total or near-total esophageal occlusion obtained a satisfactory or acceptable clinical result. Swallowing was restored, weight gain took place, but over the two and one half years that he survived his dietary intake was somewhat restricted and selective (Fig. 22). During the postoperative followup 6 patients required from one to three esophageal dilatations during the early postoperative course, and two patients with severe longitudinal strictures required monthly dilatations up to one year. One patient among the group has now been followed 3 years, two patients have been observed between 2½ and 3 years, two patients have been followed 2 to 2½6 years, six patients have been followed 1 to 2 years, and five
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patients have been observed during a rather short period of 6 to 12 months (Fig. 23). Discussion Resectional procedures and esophagogastroplasties have been widely used for correction of advanced reflux strictures. Although such operations have generally resulted in long term satisfactory results, operative morbidity and mortality have been distracting features. The decision to employ these procedures has usually been made on the basis of preoperative esophagraphy and endoscopic studies. Hayward,13 in 1961, aware of the disadvantages of resectional operations, reported 14 consecutive cases of far-advanced reflux stricture treated by intraoperative dilatation with a concomitant antireflux procedure. He employed mainly the left transthoracic approach and advised forceful dilatation of the stricture from above with simultaneous dilatation via a gastrotomy using Hegar dilators. He emphasized that with a tight, fibrotic stricture and periesophagitis, the muscular coat of the esophagus in the strictured area was always less involved with the inflammatory reaction, and by splitting the stricture from within, an adequate lumen could be restored. He decried the widespread delusion that abnormal fibrous tissue is of necessity permanent, and showed that following correction of reflux the damaged esophagus could be restored to normal or near-normal function. The magnitude of many operations for correction of reflux stricture with the associated morbidity and mortality prompted Hill to apply the simplified technique of intraoperative dilatation and posterior gastropexy. In 1970 he reported 36 cases with 85% good to excellent results. Twenty-five of his patients presented with longitudinal strictures, some extending proximally to the
6 5 Pts.
ii
During a recent 3-year period, 17 consecutive patients were seen with advanced fibrotic esophageal strictures secondary to alkaline-acid-pepsin reflux. From detailed preoperative evaluations alone it was impossible to determine whether therapy should consist of excisional surgery, esophagogastroplasty or intraoperative dilatation with correction of reflux. Only at operation could the length, extent, degree and severity of the stricture be fully determined. Each of the 17 patients was treated by controlled dilatation, coupled with an antireflux procedure. This simplified approach proved successful on strictures thought preoperatively to be undilatable. It appears that this conservative approach is applicable to many advanced strictures and excisional and plastic procedures should be reserved for those cases that prove unyielding to intraoperative dilatation. The true appraisal of a reflux stricture and the choice of surgical procedure is best determined at the operating table.
T HE DEVELOPMENT of an esophageal stricture secondary to reflux esophagitis is usually the result of failure of medical treatment or patient neglect and may be preventable. It is an unpredictable phenomenon and may present either early or late in the symptomatic patient. The stricture may be short and annular or longitudinal and ascending. In the former the inflammatory reaction is usually confined to the esophageal mucosa and submucosa, and the stricture is located at or near the gastroesophageal junction. In the latter there is usually extensive transmural involvement which may spread to the periesophageal and mediastinal structures. Such strictures may extend proximally to the level of the aortic arch, and the esophagus below the stricture may or may not be lined with columnar epithelium. 1,17.18 Controversy continues to exist regarding the surgical management of the reflux stricture and a wide range of operative procedures has been suggested. Some au-
thorities feel that operations of considerable magnitude as esophageal resection with jejunal or colonic interposiPresented at the Annual Meeting of the Southern Surgical Associa-
tion, December 9-11, 1974, Boca Raton, Florida.
From The Department of Surgery, Vanderbilt University Medical Center and the Surgical Services of St. Thomas Hospital, Vanderbilt University Hospital and The Metropolitan General Hospital Nashville, Tennessee
tion or esophagogastroplasties of the Thal-Nissen, Collis, or Heimlich types are necessary to achieve success. Valvular esophagogastrostomy and stricture excision combined with vagotomy-antrectomy with either Roux-en-Y diversion or Henley loop construction have been employed. Transgastric excision of annular strictures combined with an antireflux procedure has also been reported with good results. l 8'9"" 114"19,23,25,30,38,41,43 The preoperative assessment of an esophageal stricture using barium swallow, cin6fluoroscopy, endoscopy with biopsy, and attempts at dilatation may at times be misleading. Actual stricture length and degree of esophageal fixation and fibrosis may not always be accurately determined by such studies. Therefore to chose a particular surgical procedure on the basis of such clinical information would appear unsound. Hayward12'13 of Australia was perhaps the first to emphasize that selection of operation should be made at the time of surgery after the extent and degree of the stricture have been thoroughly ascertained. Operative findings correlated poorly with preoperative evaluation in his experience. Hayward found that many tough, fibrous strictures in patients with persistent dysphagia could be treated by operative dilatation accompanied by an antireflux procedure, and seldom was resectional surgery necessary. In this country Hill15"16 has pursued the simplified approach and has convincingly shown that advanced strictures respond to this method of therapy. Moran 21 likewise stresses that the exact extent and degree of an esophageal stricture can only be determined at operation and many advanced strictures of long standing can be- successfully
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17 Patients
menme
Age Range: 46 -90 yrs Average Age: 63 yrs
DURATION OF SYMPTOMS: 18mos-30yrs FIG. 1. Reflux Esophageal Stricture.
dilated intraoperatively and a satisfactory result obtained if associated reflux is corrected. Brindley,4 Paulson23'24 and Boyd3 have each noted satisfactory results with this method. The purpose of this communication is to cite a recent three-year experience in which this conservative surgical approach was used in the management of a small group of 17 consecutive patients with advanced reflux stricture. Material
553
Method The conservative approach to the treatment of reflux stricture may not be applicable to all cases, therefore preoperative discussions with the patient, the operating team, and nursing personnel give consideration to the possible performance of a more radical procedure should the stricture prove unyielding to intra-operative dilatation. The abdomen is first opened and after general exploration attention is directed to the left upper abdominal quadrant. The suspensary ligament of the left hepatic lobe is divided and the lobe retracted to the right. The peritoneal and fibrous structures about the proximal stomach and distal esophagus are freed next. The cephalad portion of the gastrohepatic omentum is transected, and the greater gastric curve mobilized by dividing the uppermost vasa brevia vessels. If the stricture is of the longitudinal type or the annular variety that proved unyielding on preoperative assessment, a short transverse gastrotomy is performed on the anterior wall of the cardia just below the gastroesophageal junction and held open with Guy sutures. The gastroesophageal orifice is visualized and palpated digitally to determine the degree of stenosis present. With the fingers of the surgeon's left hand placed behind and around the proximal cardia and distal esophagus, the stenosed gastroesophageal aperture is gently dilated with graduated Hegar dilators. Simultaneously, a member of the operating team passes a rigid gastroscope via the oral route to the proximal limit of the stricture. Graded filiform dilators are then passed through the stricture followed by tapered Maloney dilators. A number 20F is used initially followed by graduated sizes up to a number 34 to 38F. The rigid gastroscope is removed as the larger Maloney dilators are
There were 9 men and 8 women among the group of 17 patients comprising the clinical study. The ages ranged from 46 to 90 years with the average age being 63 years. Symptoms suggesting reflux esophagitis were present from 18 months up to 30 years. Two patients had undergone unsuccessful surgical attempts for correction of gastroesophageal reflux (Fig. 1). Severe and persistent dysphagia was experienced by each patient. Eight patients had complete or near complete obstruction to liquid intake, and three patients had difficulty swallowing their saliva. The remaining patients could not 'partake of solid food. The preoperative workup included barium examination of the esophagus and upper gastrointestinal tract when possible, cinefluoroscopy, and esophagoscopy with biopsy. The presence of carcinoma was ruled out in each of the cases. Barium enema examination was done to assess colonic length and to exclude colonic disease should a colon interposition procedure prove necessary. In 10 cases the stricture was of the longitudinal type, and in 7 cases a short distal annular stricture existed (Fig. 2). ANNULAR In some of the latter cases preoperative dilatation was LONG ITUDINAL attempted but proved unsuccessful. Dilatation was 7 cases 10 cases primarily carried out as an integral part of the operative FIG. 2. Types of esophageal strictures encountered among the 17 patients. procedure in all cases.
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FIG. 3. Sketch depicting simultaneous antegrade and retrograde dilatation of a longitudinal esophageal stricture.
Surg. * May
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small sliding esophageal hiatus hernia with gastroesophageal reflux. Esophagoscopy at the time showed evidence of esophagitis, but there was no stricture formation. She was treated with a bland diet, antacids and told to sleep with the head of her bed elevated. The patient followed these instructions for a few weeks, but did not improve and therefore discontinued medications as well as her physician's advice. During the next several weeks she noted progressive dysphagia and lost 30 pounds in weight. She experienced no melena or hematemesis. When seen at our institution a barium swallow re-
vealed a stricture of the lower esophagus and the barium
pill failed to progress through the strictured area. Endosintroduced. During this time the operator continues to dilate the distal limits of the stricture via the gastrotomy and the tapered dilators introduced from above will be seen to pass gradually through the length of the stricture. With the stricture now open larger Maloney dilators may be safely passed from above while the operator clearly visualizes the interior of the distal esophagus. With the left hand positioned around the esophagus he can determine the extent to pursue the dilatations from above (Fig. 3). After satisfactory dilatation the gastrotomy is closed and the attenuated defect in the right crural sling is approximated if the gastroesophageal junction lies below the diaphragm without tension. Should it prove difficult or impossible to bring the gastroesophageal junction below the diaphragmatic level, it is best to leave the crural aperture unapproximated with a small portion of gastric cardia displaced in the posterior mediastinum. In two of the present cases a small portion of the cardia was left above the level of the diaphragm. In two other cases the crural defect was small and the muscle fibers were purposely not approximated. Each of the 17 patients was found to have a sliding esophageal hiatal hernia. As the final important step an antireflux procedure is carried out. Fifteen patients underwent a Nissen fundoplication operation, one had a Hill posterior gastropexy, and a Belsey repair was used in one patient (Fig. 4). Two patients had an associated duodenal ulcer, and vagotomy and pyloroplasty were done. Eight patients among the group required simultaneous antegrade and retrograde intraoperative dilatation, whereas 9 patients underwent antegrade dilatation only.
copy showed a localized annular stricture 36 cm from the incisor teeth, and mucosal biopsy revealed no evidence of malignancy. Only the smallest Maloney tapered dilator (20F) could be passed through the strictured area with difficulty. At operation the gastroesophageal junction was freed up and a small sliding esophageal hiatal hernia was present. Esophageal dilatation was carried out via the oral route by a member of the operating team using graduated Maloney dilators, beginning with a 20F and gradually increasing to a 40F. During manipulation from above, the operator from below, with the fingers of his left hand around the distal esophagus, guided the graduated Maloney dilators through the stricture. The small defect in the right crural sling was repaired followed by a Nissen
fundoplication. During a 9 month followup the patient has remained asymptomatic. She has regained her lost weight, and postoperative esophageal dilatation has not been necessary. Several repeat barium swallows during this time reveal the lower esophagus to be essentially normal (Fig. 5). Endoscopy likewise reveals normal findings. Comment. Although this patient had been experiencing symptoms of gastroesophageal reflux for a number of years, she developed the annular stricture over a relatively short period of several weeks. It was not necessary to dilate the stricture through a gastrotomy incision as controlled dilatation by a member of the operating team
Illustrative Cases Case I M.H.: A 46-year-old woman was admitted to St. Thomas Hospital 3/20/74 with a 10-year history of upper abdominal discomfort, frequent eructations and 15 cases substernal burning. Four months before admission she FIG. 4. Types had been evaluated elsewhere and was told that she had a tients.
I case
I case
of antireflux procedures performed among the 17 pa-
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hiatus hernia and no evidence of malignancy was present. Preoperative esophageal dilatation was not performed. At laparotomy a moderate size sliding esophageal hiatus hernia existed. It was elected to first attempt dilaFIG. 5A. Case 1: Preoperatation of the esophageal stricture from above by a tive esophagram showing a distal annular esophageal member of the operating team. The 20F tapered Maloney stricture with the barium dilator was passed through the stricture and after careful pill trapped just above the strictured area. and meticulous manipulations additional graduated dilators up to a 38F were passed. The defect in the crural sling was approximated as the gastroesophageal junction could be brought below the diaphragmatic level without tension. A Nissen fundoplication was carried out and the gastroesophageal orifice was calibrated over a No. 38 working from above in conjunction with gudiance from Maloney dilator. The dilator was then removed and a nasogastric tube was passed into the stomach. A bilateral below proved successful. Case 2-J.F. A 62-year-old Negro man was admitted to truncal vagotomy and Weinberg type pyloroplasty were St. Thomas Hospital 11/6/73 with a 12 year history of performed for the channel ulcer (Fig. 7). Following the antireflux procedure the patient was reburning epigastric- pain, relieved somewhat by the intake of food, along with substernal distress and frequent reg- lieved of dysphagia and after a one year follow-up has no urgitation. During the past year he noted progressive symptoms of dysphagia and currently was unable to swallow solid food. Barium studies revealed a striking longitudinal narrowing of the distal esophagus and the presence of a moderate size sliding esophageal hiatus hernia. There was also a pronounced deformity of the distal pylorus and duodenal bulb consistent with the diagnosis of channel ulcer (Fig. 6). Esophagoscopy demonstrated marked narrowing of the esophagus above the level of the
FIG. SB. Postoperative barium study showing complete correction of the stricture. The deformity at the gastroesophageal junction depicts the Nissen fundoplication.
FIG. 6. Case 2: Preoperative barium esophagogastrointestinal study depicting a tight, longitudinal esophageal stricture with a moderate size sliding esophageal hiatus hernia. Also a rather marked deformity of the distal pyloric channel and duodenal bulb exist.
Ann. Surg.
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Case 3-H.N. A 55-year-old man entered St. Thomas Hospital 4/5/73 with the complaint of severe dysphagia. For several months he had not been able to partake of solid foods. Five years prior he had undergone an Allison repair for a sliding esophageal hiatus hernia. The patient was relieved of symptoms until approximately one year prior to the present admission when he experienced difficulty swallowing. There had been a 15 pound weight loss. Upper gastrointestinal study in the early postopera- Esophagram revealed an advanced distal longitudinal tive period shows correction of stricture along with a recurrent hiatus hernia. the esophageal stricture and Esophagoscopy showed the presence of the stricture and hiatus hernia. The gastroesophageal junction has been calibrated a biopsy demonstrated no evidence of malignancy. Preoperative attempt at esophageal dilatation performed over a No. 38 Maloney dilator and an antireflux operation per- elsewhere was unsuccessful. Further dilatation was not formed. pursued at our institution. At operation the recurrent hiatal hernia was reduced with some difficulty, and through an anterior gastrotomy, the gastroesophageal junction, which was extremely stenosed, was dilated with graduated Hegar dilators. Simultaneously, a member of the operative team from above dilated the proximal aspect of the stricture, employing graduated filiform dilators passed through the rigid gastroscope. The scope was withdrawn and graduated tapered Maloney dilators, up to a 38F, were symptoms referable to the gastro-intestinal tract. A re- introduced through the stricture. A No. 15 Hegar dilator cent barium study of the esophagus and stomach reveals was finally passed retrogradely, thus opening the entire only slight narrowing at the area of the previous stricture strictured area. The crural sling was next approximated and endoscopic examination shows no evidence of and a Nissen fundoplication was performed over a 38F esophagitis. The ulceration in the duodenum remains Maloney dilator. healed (Fig. 8). The patient has now been followed 20 months, has Comment. Although this patient had a tight longitudi- gained 30 pounds and experiences no difficulty swallownal stricture above the sliding esophageal hiatal hernia it ing. A recent barium study of the upper gastrointestinal was possible to dilate the stricture adequately from above tract reveals no evidence of reflux and the diameter of the and retrograde dilatation through a gastrotomy was not distal esophagus is within normal limits (Fig. 9). necessary. Comment. Combined antegrade and retrograde dilataFIG. 7. Case 2:
FIG.
8.
Case
2:
Barium
study one year postoperative reveals no evidence of recurrent stricture or her-
nia formation. The patient has been relieved of all symptoms.
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FIG. 9. Case 3: (Left) Barium swallow showing the advanced, longitudinal stricture with associated hiatus hernia. (Right) Upper gastrointestinal barium study 20 months postoperative reveals no evidence of recurrent stricture formation and no hiatus hernia.
4a .
tion of the strictured esophagus proved necessary in this she was only able to swallow liquids and experienced a 20 case. In our opinion neither approach alone would have pound weight loss. She had noted heartburn and epigassufficed in alleviating the esophageal stenosis. Prepara- tric fullness over the past 12 years, and 5 years before tions had been made prior to operation to perform a more admission an upper gastrointestinal study revealed the radical procedure such as colon interposition had com- presence of a sliding esophageal hiatal hernia. Aside from bined efforts at dilatation been unsuccessful. the occasional use of Donnatal and Valium she had had Case 4-M.P. A 68-year-old woman was admitted to St. no specific treatment. Thomas Hospital 10/1/73 with a one year history of proBarium swallow revealed a striking, tapering stenosis gressive difficulty in swallowing. Within recent months of the distal esophagus with the lumen measuring 2 mm, at its narrowest point. Distal to the stenosed area a fine trickle of barium outlined a small hiatus hernia (Fig. 10). Esophageal biopsy showed no evidence of tumor. At operation, through a midline abdominal incision, a high gastrotomy opening was made and retrograde dilatation of the stricture was carried out using graduated Hegar dilators. Simultaneously, the stricture was dilated from above using filiform dilators followed by graduated tapered Maloney bougies. The esophagogastric junction was brought below the diaphragmatic level without tension, and the right crural sling was approximated. A Nissen fundoplication was performed over a 36F Maloney dilator. The patient has been carefully followed for 14 months and has not required subsequent dilatation. Symptoms have been relieved and a recent barium study of the upper gastrointestinal tract reveals the esophagus to be entirely normal (Fig. 11). Comment. This patient presented with an extremely tight and fibrotic stricture of the distal esophagus which was longitudinal in type. From a study of the preoperative esophagram some doubt was raised as to whether this stricture could be dilated intraoperatively. However, FIG. 10. Case 4: Preoperative barium swallow demonstrating a tapering the combined approach adequate dilatation was using stenosis of the distal esophagus with an esophageal lumen measuring 2 mms. performed, followed by an antireflux procedure.
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-_w
1.
FIG. 11. Case 4: (Left) Barium swallow on the 7th postoperative day reveals some increase in the diameter of the esophageal lumen as compared to the preoperative study. (Right) Upper gastrointestinal contrast study 14 months postoperative reveals the esophagus and esophagogastric junction to be perfectly normal. The patient was relieved of all symptoms during the early postoperative period and did not require additional dilatation.
Ann. Surg.
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posely not reapproximated. The operator was unable to displace the lower few centimeters of the esophagus below the diaphragm without producing tension on the former structure. Therefore a portion of the fundoplication was left above the diaphragmatic level, and the edge of the diaphragm was sutured loosely to the mid aspect of the fundoplication. Postoperatively the patient did well but necessitated dilatation on two occasions for mild upper abdominal discomfort. Esophagoscopy shows no evidence of reflux or esophagitis and a barium swallow 6 months postop revealed improvement over the early postoperative study with only slight narrowing at the former stricture site. The esophageal lumen, however, appears adequate. The Nissen fundoplication may be seen lying partially in the posterior mediastinum and it functions adequately in preventing reflux (Fig. 13). Comment. This annular stricture. could undoubtedly have been adequately excised through a transgastric approach. However, dilatations from above proved adequate and obviated the need for anterior gastrotomy. Some, perhaps, might have elected to treat this stricture by the more complicated method of Thal. Case 6-U.B. A 68-year-old woman was admitted to the Metropolitan General Hospital 10/10/71 with a 30 pound weight loss and progressive dysphagia over a period of 6 months. Recently she had experienced difficulty in swallowing liquids. Past history showed that for at least 10
Case 5-A.H. A 49-year-old man was admitted to St. Thomas Hospital 6/25/74 with a 3 year history of upper abdominal discomfort, substernal burning and frequent regurgitation. He had been diagnosed elsewhere as having a sliding esophageal hiatus hernia and appropriate medical treatment was instituted. However, symptoms progressed in severity and he began to experience dysphagia. He could not swallow solids and it was necessary for his wife to puree his food. Barium study revealed a tight, annular, distal esophageal stricture and just below the stricture was a moderate size sliding esophageal hiatus hernia (Fig. 12). Biopsy ruled out the presence of carcinoma and all other findings were normal. Through an abdominal approach the esophageal hiatal hernia was freed up and the distal esophagus exposed. With the fingers of the operator's left hand surrounding the esophagus, a member of the operating team from above passed the graded Maloney dilators through the stricture site beginning with a No. 20F and progressing to a 44F. A Nissen fundoplication was then performed over FIG. 12. Case 5: Preoperative barium study shows a tight, annular, a No. 38F Maloney dilator and the crural sling was pur- distal esophageal stricture with a sliding esophageal hiatus hernia.
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FIG. 13. Case 5: Barium study 6 months postoperative reveals only slight narrowing at the former stricture site. The Nissen fundoplication may be seen lying partially in the posterior mediastinum. This patient required dilatation on two occasions during the early postoperative period, after which he has been relieved of all symptoms.
years she had noted heartburn, upper abdominal fullness and substernal distress. A hiatus hernia was diagnosed at that time but the patient had not followed medical therapy. Barium examination of the esophagus revealed a tight, longitudinal stricture, and distal to the narrow barium column a small hiatus hernia was visualized (Fig. 14). Biopsy taken from the proximal limit of the stricture showed no evidence of malignancy and preoperative dilatation was not attempted. At operation, employing a left thoracotomy, the longitudinal stricture was dilated from above while the operator controlled the dilatations with his fingers about the mobilized esophagus. A Belsey Mark IV antireflux procedure was then carried out. The patient required several dilatations during the first few post-orerative
months and the stricture was gradually dilated up to a Maloney 44F. An upper gastrointestinal study 3 years postoperative revealed the esophagus to be normal (Fig. 15). No reflux can be demonstrated on endoscopy and no recurrent hiatus hernia is noted. The patient does experience mild to moderate upper abdominal burning pain which is controlled with medications. Comment. This case represents a tight, longitudinal stricture of the distal one-third of the esophagus which some surgeons prefer to treat by an interposition procedure or esophagogastroplasty. A less formidable procedure, however, sufficed to alleviate this patient's dysphagia completely. Case 7-J.R. A 69-year-old Negro man was admitted to St. Thomas Hospital 10/5/72 with a 30 year history of
I
L,.As FIG. 14. Case 6: Preoperative esophagram showing an advanced, longitudinal stricture of the lower esophagus.
FIG. 15. Case 6: Gastrointestinal study 3 years postoperative reveals the caliber of the esophageal lumen to be normal. The Belsey Mark IV antireflux procedure continues to function adequately.
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anterior gastrotomy with graded Hegar dilators and from above by first employing filiform catheters, followed by graduated tapered Maloney dilators up to a No. 34F. The crural sling was approximated and a posterior gastropexy as described by Hill was used to correct reflux. Postoperatively the patient did well and was able to progress to soft food. Dilatations were continued for several months and he was able to eat a soft diet but certain foods were poorly tolerated. Adequate nutrition was maintained and the patient was satisfied with the clinical result. An x-ray 18 months after operation showed mild dilatation proximal to the original stricture but the stenosed area had opened up considerably and an ample lumen was present (Fig. 17). The patient was followed for a period of two and one half years at which time he died of a cerebrovascular accident. Comment. This elderly gentleman presented with a far-advanced fibrotic longitudinal stricture and preoperative opinions from several authoritative consultants were that a radical approach to the stricture would be necessary. However, combined dilatation from above and below along with the antireflux procedure produced an acceptable result. Case 8-V.B. A 53-year-old woman was admitted to Metropolitan City Hospital 5/25/72 with a 6 year history of upper abdominal fullness, heartburn and regurgitation. FIG. 16. Case 7: Barium study showing a far-advanced longitudinal stricture with dilatation of the esophagus proximal to the stricture.
upper abdominal fullness and substernal discomfort. For the past 12 weeks before admission he experienced progressive dysphagia and had difficulty swallowing liquids. He had lost 40 pounds in weight and experienced marked lassitude and fatigue. Upon admission the patient appeared acute and chronically ill and showed evidence of marked weight loss. He had difficulty swallowing his saliva. The hemogram was 10, albumin was 2.2 and total serum protein was 5.8. Extensive workup was done including an upper gastrointestinal study which showed dilatation of the proximal esophagus, and beginning 33 cm, from the incisor teeth there was an advanced fibrous stricture (Fig. 16). However, after several minutes of fluoroscopic observation, a trickle of barium was seen to pass through the strictured area. At endoscopy the proximal limit of the stricture was visualized and a biopsy showed no evidence of tumor. A No. 4 filiform catheter could not be introduced through the stricture. The patient was given adequate blood and colloid replacement and put on total parenteral hyperalimentation for a period of 3 weeks. During this time he gained 15 pounds and his general condition improved considerably. At operation the stricture was dilated retrogradely via
"74
FIG. 17. Case 7: Contrast study of the esophagus 18 months postoperative reveals minimal dilatation of the proximal esophagus, but the lumen through the previous strictured area appears adequate. Esophageal dilatations were necessary for several months postoperative, but this elderly patient was able to eat a soft diet without difficulty.
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561 markedly dilated with evidence of retained fluid. No peristaltic activity was present and esophageal emptying took place by increased hydrostatic pressure with the patient erect. Distal to the dilatation an advanced longitudinal stricture was noted (Fig. 18). Esophagoscopy confirmed the diagnosis of a pronounced esophageal stricture and biopsy at the proximal limit of the stricture showed no evidence of malignancy. *} After adequate preoperative preparation the stricture T was dilated using the combined approach followed by a Nissen fundoplication. Several dilatations were instituted for a few weeks postoperatively after which they were discontinued. During the ensuing months the patient gained 47 pounds and a barium swallow showed marked improvement. She has been seen at frequent intervals during the past two and one half years, has no dietary limitations, and is symptom-free. A recent esophagram reveals a slight narrow area in the distal esophagus but the lumen through this area measures almost one cm. (Fig. 19). Comment. This patient also presented with an advanced fibrotic stricture and one could not determine from preoperative assessment whether intraoperative dilatation would be possible. However, intraoperative combined dilatations followed by an anti-reflux operation FIG. 18. Case 8: Preoperative barium swallow shows marked dilatat proved effective in eliminating symptoms and restoring iton of the proximal esophagus with retained food and secretions. Dista the dilatation a striking longitudinal esophageal stricture is present. T hist the esophagus to near normal. Although slight narrowing patient had difficulty swallowing her saliva. of a segment of esophagus exists, it has caused the patient no symptoms over a two and one half year followup. During the past year she had experienced difficulty'in Case No. 9-L.R. A 90-year-old Caucasian man was swallowing and currently was only able to partake f a admitted to St. Thomas Hospital 10/3/71 with a history of liquid diet. dyspepsia dating back at least 40 years. He had been told An esophagram revealed the proximal esophagus to be that he had an esophageal hiatal hernia, but had never
FIG. 19. Case 8: (Left) An esophagram during the early postoperative period after 2 dilatations reveals only slight narrowing with longitudinal stricture. (Right) An
correction of the
esophagram 2 years postoperative reveals only slight esophageal narrowing and the patient has obtained an excellent result.
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preoperative preparation with total parenteral nutrition the patient was taken to surgery. Employing simultaneous antegrade and retrograde dilatation of the longitudinal stricture, a 30F Maloney dilator was finally passed into the stomach. The crural sling was approximated and a Nissen plication done. Postoperatively the patient was dilated with the smaller Maloney dilators and was able to swallow liquids and soft food. Following discharge dilation was done frequently during the first 6 months and monthly dilatations were continued to one year. At the end of this time a barium swallow showed marked narrowing of the distal one-third of the esophagus but surprisingly the patient had no difficulty eating soft foods (Fig. 21). He could not, however, tolerate solids. Weight gain took place and he remained in fairly good health until he died two and one half years postoperative, apparently from a myocardial infarction. Comment. This elderly man presented with a faradvanced esophageal stricture in which the lumen was all but completely occluded. Had this patient not been of advanced age and relatively free of associated constitutional disease a colonic orjejunal interposition procedure would have been performed. It is surprising however, that operative dilatation and correction of reflux were effective to a great degree in alleviating his total obstruction and allowing him to eat a restricted diet. Results and Followup Sixteen of the 17 patients survived operation and have been carefully followed. One patient, a 72-year-old man FIG. 20. Case 9: Complete esophageal obstruction resulting from benign reflux stricture. This 90-year-old patient could not swallow liquids and had difficulty swallowing his saliva.
been advised to follow a medical program. Eight years before admission he underwent a cholecystectomy and during the postoperative course a nasogastric tube was kept in place for several days. Following discharge from the hospital dyspepsia increased and he experienced rather severe substernal distress and regurgitation. He noted progressive difficulty swallowing solid foods and for the next several years consumed a soft diet. Several months before admission he noted difficulty swallowing liquids and for a few weeks prior to admission had difficulty swallowing his saliva. He lost about 40 pounds during this period and experienced marked weakness and fatigue. Upon admission the patient appeared chronically ill and the hemogram was 9.4. A barium swallow revealed FIG. 21. Case 9: Postoperative barium study after one year shows marked dilatation of the proximal exophagus and com- diminution in the caliber of the previously dilated proximal esophagus. plete obstruction was noted at the junction of the middle The strictured area still persists, but the esophageal lumen throughout and distal third (Fig. 20). Esophagoscopy confirmed the this area shows considerable improvement as compared to the of some persistent esophageal narrowing. presence of complete obstruction but no evidence of a preoperative state. In spite able to take a restricted diet, gained weight, this 90-year-old patient was tumor was noted. After an extensive workup and and was markedly improved.
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FIG. 22. Follow-up results for 16 patients. GOOD 25%(4) I Hositl Deoth in
IMPOVED 6%(1) Original 17 Patlmt
with pre-existing cardiac disease developed a cerebrovascular accident during the early postoperative period and expired. Two patients have since died of unrelated causes, each two and one-half years postoperative but are included in the followup. Each living patient has been observed at frequent intervals and esophagoscopy and barium contrast studies of the upper gastrointestinal tract have been part of the postoperative evaluation. Eleven patients have obtained an excellent clinical result, experience no upper abdominal discomfort, and have no dietary restrictions. Four patients are termed a good result since each experiences mild and intermittent abdominal discomfort. One of the 4 has subjective evidence of reflux but esophagoscopy shows no demonstrable reflux or esophageal mucosal changes. This patient had a Belsey repair as the antireflux procedure in contrast to most of the group who underwent a Nissen fundoplication. Another patient with a good result had undergone a prior operation for reflux and also had a leiomyoma removed from the esophagus. The third patient listed as a good result had almost complete esophageal occlusion prior to operation. The fourth patient, likewise, presented with a far-advanced longitudinal stricture. Following dilatation and correction of reflux he has tolerated soft foods well but certain solid foods cause mild upper abdominal distress. The 90-year-old man with total or near-total esophageal occlusion obtained a satisfactory or acceptable clinical result. Swallowing was restored, weight gain took place, but over the two and one half years that he survived his dietary intake was somewhat restricted and selective (Fig. 22). During the postoperative followup 6 patients required from one to three esophageal dilatations during the early postoperative course, and two patients with severe longitudinal strictures required monthly dilatations up to one year. One patient among the group has now been followed 3 years, two patients have been observed between 2½ and 3 years, two patients have been followed 2 to 2½6 years, six patients have been followed 1 to 2 years, and five
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patients have been observed during a rather short period of 6 to 12 months (Fig. 23). Discussion Resectional procedures and esophagogastroplasties have been widely used for correction of advanced reflux strictures. Although such operations have generally resulted in long term satisfactory results, operative morbidity and mortality have been distracting features. The decision to employ these procedures has usually been made on the basis of preoperative esophagraphy and endoscopic studies. Hayward,13 in 1961, aware of the disadvantages of resectional operations, reported 14 consecutive cases of far-advanced reflux stricture treated by intraoperative dilatation with a concomitant antireflux procedure. He employed mainly the left transthoracic approach and advised forceful dilatation of the stricture from above with simultaneous dilatation via a gastrotomy using Hegar dilators. He emphasized that with a tight, fibrotic stricture and periesophagitis, the muscular coat of the esophagus in the strictured area was always less involved with the inflammatory reaction, and by splitting the stricture from within, an adequate lumen could be restored. He decried the widespread delusion that abnormal fibrous tissue is of necessity permanent, and showed that following correction of reflux the damaged esophagus could be restored to normal or near-normal function. The magnitude of many operations for correction of reflux stricture with the associated morbidity and mortality prompted Hill to apply the simplified technique of intraoperative dilatation and posterior gastropexy. In 1970 he reported 36 cases with 85% good to excellent results. Twenty-five of his patients presented with longitudinal strictures, some extending proximally to the
6 5 Pts.
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