Br. J. Surg. Vol. 66 (1979) 607-608
Dysphagia following selective vagotomy S. I. S U L E I M A N , S. A. M A G L A D A N D M. HOBSLEY * SUMMARY
Pvogression of dysphagia after vagotomy to the stage o j complete obstruction due to a peri-oesophageal fibrotic collar needing operation is a rare event. Review of the 4 such cases previously described, all needingfurther operation andall after truncal vagotomy, indicates that the oesophageal mucosa was normal on oesophagoscopy and that bouginage appeared to make the condition worse. This pager describes the first patient in whom ( a ) the vagotomy was selective and (6) no bouginage was carried out before the condition was relieved by a further surgical operation.
IN this paper we describe a very rare cause of dysphagia following vagotomy and indicate how to diagnose and treat the condition. Case report A 58-year-old male Sudanese, with a 15-year history typical of duodenal ulcer pain, had recently started vomiting. The barium meal showed a deformed duodenal cap with pyloric outlet obstruction. On 24 March 1976 he underwent selective vagotomy (Tanner, 1966) with a Heineke-Miculicz pyloroplasty. He made an uneventful recovery, started eating solid food on the fifth day and was allowed home on the tenth day on a full diet. On 14 April the patient was readmitted complaining of dysphagia with a mild retrosternal pain and regurgitation. The dysphagia had commenced a week after discharge from hospital, i.e. 2 weeks after the operation. At first there had been difficulty only with solids, but within 3 days the dysphagia had progressed to complete inability to swallow. Intravenous fluid therapy was started. When a barium swallow was performed the contrast medium reached the lower oesophagus and was regurgitated. Fibre-endoscope oesophagoscopy showed a normal mucosa but the lumen of the lower oesophagus was irregular and narrowed and would not yield to the 7-mni fibre endoscope. After 48 h a thin Gastrografin swallow showed a narrowed lower oesophagus and there was a trickle of contrast medium into the stomach (Fig. 1). On 18 April the patient was re-explored. The lower oesophagus, denuded a t the previous operation, was found to be surrounded by tough fibrous tissue, particularly anteriorly and laterally, The fibrous tissue was easily dissected from the oesophageal muscle but was firmly adherent to the perioesophageal tissue. The fibrotic collar was removed and both silk sutures previously used for ligating the vagai trunks were found amidst the tough tissues. The patient’s postoperative recovery was uneventful and he could swallow solid food within a week. At follow-up, 18 months later, the patient remained symptom-free.
Discussion Many believe that vagotomy denervates the lower oesophageal sphincter mechanism and leads to loss of peristalsis and a form of achalasia (Moses, 1947; Harris and Miller, 1960). However, Edwards (1970) showed by radiology and manometry in patients with post-vagotomy dysphagia that the lower oesophageal sphincter was intact and that peristalsis occurred normally. Denervation of the lower oesophagus in dogs is only achieved by vagal section high in the hila of the lungs (Carveth et al., 1962); this may be why the incidence of dysphagia is higher after transthoracic vagotomy (Grimson et al., 1947) than
Fig. 1. Gastrografin swallow showing narrowing of the lower oesophagus which proved to be due to pen-oesophageal fibrosis.
after abdominal vagotomy (Wirthlin and Malt 1972). Post-vagotomy dysphagia can certainly be caused by oesophagitis due to reflux, with or without a hiatus hernia (Beal, 1948; Clarke et al., 1965; Johnson, 1965). Reflux oesophagitis can be diagnosed by oesophagoscopy. The literature (Bruce and Small, 1959; Guillory and Clapget. 1967: Postlethwaite et al.. 1969; Spencer. 1975) aGo describes 4 patients after truncal vagotomy in whom operation was needed to relieve complete oesophageal obstruction due t o pressure from a fibrous collar. In all cases the dysphagia started 2-3 weeks following the vagotomy, oesophagoscopywhen performed-showed a normal mucosa and dilatation of the oesophagus was ineffectual. It is particularly interesting to note the comment of Postlethwaite et al. (1969) that ‘for 2 months repeated dilatations were performed but the size of the oesophageal lumen gradually decreased’. Our patient is the first in whom this rare form of dysphagia occurred after selective vagotomy. Presumably the condition can also arise after proximai gastric vagotomy, as in all forms of vagotomy the lower oesophagus is denuded. The differentiation of ~~
* S.
~
I. Suleiman, Department of Surgery, University of Khartoum, now Bowater-Ralli Fellow, Department of Surgical Studies, The Middlesex Hospital. S. A. Maglad, ENT Surgeon, Khartoum Hospital. M. Hobsley, Department of Surgical Studies, The Middlesex Hospital, London. Correspondence to: M. Hobsley.
608
S. I. Suleiman et al.
this rare complication from dysphagia due to oesophagitis depends on the characteristically short time interval between the operation and the onset of symptoms (7-21 days), the relentless progression to complete, or nearly complete, inability to swallow and the finding on endoscopy of normal mucosa at the lower end of the oesophagus. The evidence of the previously described 4 cases suggests that bouginage is ineffective, because the rigid fibrotic collar cannot be stretched, and repeated attempts at bouginage cleary carry a risk of perforation of the oesophagus. We therefore suggest that the correct management should be early laparotomy and excision of the fibrous mass, without preliminary abortive attempts at oesophagoscopic dilatation. We successfully adopted this policy in the management of our patient.
References (1948) Diaphragmatic hernia following subdiaphragmatic vagotomy. Surgery 24, 625-627. BRUCE J. and SMALL w. P. (1959) Dysphagia following vagotomy. J. R . CON.Surg. Edinb. 4, 170-178. CARVETH s. w., SCHLEGEL J. F., CODE c. F. et al. (1962) Esophageal motility after vagotomy, phrenicotomy, myotomy and myomectomy in dogs. Surg. Gynecol. Obstet. 114, 31-42. BEAL J. M .
s. D., PENRE J . B. and WARD P. (1965) Oesophageal reflux after abdominal vagotomy. Lancet 2, 824-826. EDWARDS D. A. w. (1970) Post-vagotomy dysphagia. Lancet 2, 90-92. GRIMSON K. S., BAYLON G. J., TAYLOR H. M. et al. (1947) Transthoracic vagotomy. J A M A 134,925-932. GUILLORY J. R. and CLAGOET 0. T. (1967) POSt-VagOtOmy dysphagia. Surg. Clin. North Am. 41, 833-839. HARRIS J. and MILLER c . M. (1960) Cardiospasm following vagotomy. Surgery 41, 568-570. JOHNSON J. R. (1965) Esophageal hiatus hernia following vagotomy. Calif. Med. 103, 438-440. MOSES w. R. (1947) Critique on vagotomy. N. Engl. J. Med. 231, 603-610. POSYLETHWAITE R. w . , KIM s. K . and DILLON M. L. (1969) Esophageal complications of vagotomy. Surg. Gynecol. Obstet. 128, 481488. SPENCER J. D. (1975) Post-vagotomy dysphagia. Br. J. Surg. 62, 3 54-3 5 5. TANNER N. c. (1966) A technique of selective vagotomy. Br. J . Surg. 53, 185-189. WIRTHLIN L. s. and MALT R . A. (1972) Accidents of vagotomy. Surg. Gynecol. Obstet. 135, 913-916. CLARKE
Paper accepted 13 March 1979.
Dysphagia following selective vagotomy S. I. S U L E I M A N , S. A. M A G L A D A N D M. HOBSLEY * SUMMARY
Pvogression of dysphagia after vagotomy to the stage o j complete obstruction due to a peri-oesophageal fibrotic collar needing operation is a rare event. Review of the 4 such cases previously described, all needingfurther operation andall after truncal vagotomy, indicates that the oesophageal mucosa was normal on oesophagoscopy and that bouginage appeared to make the condition worse. This pager describes the first patient in whom ( a ) the vagotomy was selective and (6) no bouginage was carried out before the condition was relieved by a further surgical operation.
IN this paper we describe a very rare cause of dysphagia following vagotomy and indicate how to diagnose and treat the condition. Case report A 58-year-old male Sudanese, with a 15-year history typical of duodenal ulcer pain, had recently started vomiting. The barium meal showed a deformed duodenal cap with pyloric outlet obstruction. On 24 March 1976 he underwent selective vagotomy (Tanner, 1966) with a Heineke-Miculicz pyloroplasty. He made an uneventful recovery, started eating solid food on the fifth day and was allowed home on the tenth day on a full diet. On 14 April the patient was readmitted complaining of dysphagia with a mild retrosternal pain and regurgitation. The dysphagia had commenced a week after discharge from hospital, i.e. 2 weeks after the operation. At first there had been difficulty only with solids, but within 3 days the dysphagia had progressed to complete inability to swallow. Intravenous fluid therapy was started. When a barium swallow was performed the contrast medium reached the lower oesophagus and was regurgitated. Fibre-endoscope oesophagoscopy showed a normal mucosa but the lumen of the lower oesophagus was irregular and narrowed and would not yield to the 7-mni fibre endoscope. After 48 h a thin Gastrografin swallow showed a narrowed lower oesophagus and there was a trickle of contrast medium into the stomach (Fig. 1). On 18 April the patient was re-explored. The lower oesophagus, denuded a t the previous operation, was found to be surrounded by tough fibrous tissue, particularly anteriorly and laterally, The fibrous tissue was easily dissected from the oesophageal muscle but was firmly adherent to the perioesophageal tissue. The fibrotic collar was removed and both silk sutures previously used for ligating the vagai trunks were found amidst the tough tissues. The patient’s postoperative recovery was uneventful and he could swallow solid food within a week. At follow-up, 18 months later, the patient remained symptom-free.
Discussion Many believe that vagotomy denervates the lower oesophageal sphincter mechanism and leads to loss of peristalsis and a form of achalasia (Moses, 1947; Harris and Miller, 1960). However, Edwards (1970) showed by radiology and manometry in patients with post-vagotomy dysphagia that the lower oesophageal sphincter was intact and that peristalsis occurred normally. Denervation of the lower oesophagus in dogs is only achieved by vagal section high in the hila of the lungs (Carveth et al., 1962); this may be why the incidence of dysphagia is higher after transthoracic vagotomy (Grimson et al., 1947) than
Fig. 1. Gastrografin swallow showing narrowing of the lower oesophagus which proved to be due to pen-oesophageal fibrosis.
after abdominal vagotomy (Wirthlin and Malt 1972). Post-vagotomy dysphagia can certainly be caused by oesophagitis due to reflux, with or without a hiatus hernia (Beal, 1948; Clarke et al., 1965; Johnson, 1965). Reflux oesophagitis can be diagnosed by oesophagoscopy. The literature (Bruce and Small, 1959; Guillory and Clapget. 1967: Postlethwaite et al.. 1969; Spencer. 1975) aGo describes 4 patients after truncal vagotomy in whom operation was needed to relieve complete oesophageal obstruction due t o pressure from a fibrous collar. In all cases the dysphagia started 2-3 weeks following the vagotomy, oesophagoscopywhen performed-showed a normal mucosa and dilatation of the oesophagus was ineffectual. It is particularly interesting to note the comment of Postlethwaite et al. (1969) that ‘for 2 months repeated dilatations were performed but the size of the oesophageal lumen gradually decreased’. Our patient is the first in whom this rare form of dysphagia occurred after selective vagotomy. Presumably the condition can also arise after proximai gastric vagotomy, as in all forms of vagotomy the lower oesophagus is denuded. The differentiation of ~~
* S.
~
I. Suleiman, Department of Surgery, University of Khartoum, now Bowater-Ralli Fellow, Department of Surgical Studies, The Middlesex Hospital. S. A. Maglad, ENT Surgeon, Khartoum Hospital. M. Hobsley, Department of Surgical Studies, The Middlesex Hospital, London. Correspondence to: M. Hobsley.
608
S. I. Suleiman et al.
this rare complication from dysphagia due to oesophagitis depends on the characteristically short time interval between the operation and the onset of symptoms (7-21 days), the relentless progression to complete, or nearly complete, inability to swallow and the finding on endoscopy of normal mucosa at the lower end of the oesophagus. The evidence of the previously described 4 cases suggests that bouginage is ineffective, because the rigid fibrotic collar cannot be stretched, and repeated attempts at bouginage cleary carry a risk of perforation of the oesophagus. We therefore suggest that the correct management should be early laparotomy and excision of the fibrous mass, without preliminary abortive attempts at oesophagoscopic dilatation. We successfully adopted this policy in the management of our patient.
References (1948) Diaphragmatic hernia following subdiaphragmatic vagotomy. Surgery 24, 625-627. BRUCE J. and SMALL w. P. (1959) Dysphagia following vagotomy. J. R . CON.Surg. Edinb. 4, 170-178. CARVETH s. w., SCHLEGEL J. F., CODE c. F. et al. (1962) Esophageal motility after vagotomy, phrenicotomy, myotomy and myomectomy in dogs. Surg. Gynecol. Obstet. 114, 31-42. BEAL J. M .
s. D., PENRE J . B. and WARD P. (1965) Oesophageal reflux after abdominal vagotomy. Lancet 2, 824-826. EDWARDS D. A. w. (1970) Post-vagotomy dysphagia. Lancet 2, 90-92. GRIMSON K. S., BAYLON G. J., TAYLOR H. M. et al. (1947) Transthoracic vagotomy. J A M A 134,925-932. GUILLORY J. R. and CLAGOET 0. T. (1967) POSt-VagOtOmy dysphagia. Surg. Clin. North Am. 41, 833-839. HARRIS J. and MILLER c . M. (1960) Cardiospasm following vagotomy. Surgery 41, 568-570. JOHNSON J. R. (1965) Esophageal hiatus hernia following vagotomy. Calif. Med. 103, 438-440. MOSES w. R. (1947) Critique on vagotomy. N. Engl. J. Med. 231, 603-610. POSYLETHWAITE R. w . , KIM s. K . and DILLON M. L. (1969) Esophageal complications of vagotomy. Surg. Gynecol. Obstet. 128, 481488. SPENCER J. D. (1975) Post-vagotomy dysphagia. Br. J. Surg. 62, 3 54-3 5 5. TANNER N. c. (1966) A technique of selective vagotomy. Br. J . Surg. 53, 185-189. WIRTHLIN L. s. and MALT R . A. (1972) Accidents of vagotomy. Surg. Gynecol. Obstet. 135, 913-916. CLARKE
Paper accepted 13 March 1979.
