Annals of the Royal College of Surgeons of England (I977) vol 59
IVOR LEWIS LECTURE, 1975
The advancing frontiers of oesophageal surgery R H Franklin CBE FRCS Past Vice-President, Royal College of Surgeons of England; Honorary Visiting Surgeon, Royal Postgraduate Medical School and Hammersmith Hospital, London.
Introduction Ivor Lewis was born in a 'large upland farm in North Carmarthenshire' in I895 and he spoke only Welsh until he was I 2 years old.
from exploring new ground and in I939 he reported the first successful pulmonary embolectomy in Britain. I am informed that one of his survivors from this operation atHe attended the grammar school at Llandeilo tended the hospital io years later complainuntil the age of i 9, spending the last two years ing of rheumatism. For many years he spent his annual leave on the classical side. He never ceased to be thankful for these two years, which, he writes, 'gave a balance to my future life which most students of medicine today have to go without'. He attributes his choice of medicine as a career to the fact that he had a severe attack of acute appendicitis at the age of I2-being operated upon by David Ellis of Aberystwyth, 'a general practitioner surgeon of the best type'. His education continued-first at Cardiff University and then in London, at University College and University College Hospital. After a number of house appointments he became a surgeon at Lewisham, which was one of the developing London County Council hospitals. Further experience in municipal hospitals was gained in the three years which he spent at the City Hospital in Plymouth as medical superintendent. Here he had charge of a wide range of general surgery. In I933 he was appointed medical director and surgeon at the North Middlesex Hospital and it was here that he made great contributions to surgery. In addition to his administrative duties he had charge of two wards of 30 beds, and these included thoracic as well as general surgical patients. One of his then juniors tells me that he sometimes started a list at 4 p.m. after outpatients and continued until midnight or later. FIG. I Ivor Lewis This heavy work load did not prevent him This inaugural Ivor Lewis Lecture was delivered to the North Middlesex Medical Society on the occasion of the opening of the new Academic Centre by Sir Rodney Smith KBE PRCS on 30th September I975.
The advancing frontiers of oesophageal surgery visiting centres abroad and in 1935 he spent some months in the USA. In addition to his heavy clinical responsibilities and administrative duties he found time to make autopsy studies on the oesophagus. Although he was happy in his busy life in London he never lost the nostalgic wish to return to his homeland. When the National Health Service was born his opportunity came and he found himself appointed by the Welsh Hospital Board to the new hospital development in Rhyl. His surgical career has been more varied and has embraced a wider field than would be possible or even desirable today. But it does support the view of our College that aspirant surgeons should be given a solid foundation of surgical knowledge in general before embarking on a specialty.
The development of oesophageal surgery I am particularly concerned on this occasion with Ivor Lewis's contributions to oesophageal surgery in the I940s. The preceding years had indeed presented a dismal picture. After the first successful resection of the thoracic oesophagus by Torek in 1913I attempts were made all over the world to emulate this triumph, but none succeeded until 1933, when Grey Turner successfully removed the thoracic oesophagus by the 'colloabdominal' or 'pull-through' method2. This somewhat crude procedure was necessitated by the limitations enforced by the equally crude anaesthetics which were available at that time. But it is fitting to pay tribute to the great advances in anaesthesia which did make advances possible. Early attempts at operation were restricted to removing the oesophagus by what was thought to be the least hazardous method. In the unlikely event of the patient recovering from the resection continuity could be restored at a later date. Many and ingenious were the operations devised to this end. The complexity of these procedures arose from the prevalent fear of carrying out an anastomosis within the chest and so risking an intrathoracic leak. Very few of these reconstructions were completed in patients suffering from cancer, and
285
when they were carried out -for benign conditions the development of leaks and strictures was disappointingly frequent. In spite of the appalling mortality a few surgeons persisted in their efforts and the occasional survival or even a near success was heralded as a great surgical achievement. A most important paper by Ohsawa in Japan in I9333 failed to receive the attention it deserved. In the preceding 7 years Ohsawa had been able to resect the lower oesophagus in i8 patients, 8 of whom survived. This was a most remarkable achievement. His success was due to two factors: first, he carried out the operation by means of an abdominothoracic approach; and second, he made an immediate oesophagogastric anastomosis. The importance of the immediate anastomosis was not generally appreciated at first, but Nissen repeated such an operation in I937 on a patient suffering from a benign ulcer'. Successes followed in the United States by Adams and Phemister in I9385 and in Britain by Vernon Thompson in I94,I. These early successes were concerned with growths involving the lower end of the oesophagus and were facilitated by making a leftsided abdominothoracic approach. It was natural that this approach should gain favour and there was some reluctance to abandon it even if the growth extended higher than had been anticipated. If such proved to be the case new difficulties arose. Mobilization of the middle of the oesophagus from the left side of the chest results in opening of the right pleural cavity in most cases and very often damage to the vena azygos, with severe and sometimes uncontrollable haemorrhage. Conversations with the late Mr J H Roberts, of the Brompton and St Bartholomew's Hospitals, gave me the idea of approaching the oesophagus through a right thoracotomy and in 1942 I was able to report two cases in which I had succeeded in resecting the whole of the thoracic oesophagus through the right side of the chest7. The experience of these two successful cases convinced me of the advantages of this approach, but I did not at that time appreciate the importance of making an immediate anastomosis. Ivor Lewis, however, did appreciate both points, and in a masterly Hunterian
286
R H Franklin
Lecture at the Royal College of Surgeons in reported elsewhere'0. In what direction shall we go in the search I9468 he described his operation of first mobilizing the stomach at abdominal laparotomy, for improvement in results? Will earlier then resecting the oesophagus through a right diagnosis achieve this? This may well increase thoracotomy, and in conclusion making an the resection rate, but experience with cancer immediate oesophagogastric anastomosis. I in other sites gives little hope of great improvethink that the detailed description of this pro- ment in long-term survival. Earlier diagnosis cedure constituted a major advance in oeso- is certainly desirable and is aided by cinephageal surgery. To quote his own words, radiography, improved endoscopy, and cyto'the bold early experiments in oesophageal logy, but above all by constant vigilance on surgery were followed by decades spent in try- the part of the doctor. Diagnosis may be ing to circumvent rather than face the dangers, difficult and may need revision (see Figure 2). and recently by a return to straightforward An open mind must be kept as to the value resection with anastomosis'. of X-ray therapy, by itself or in conjunction with surgery and cytotoxic drugs. ImmunoOver the years the Ivor Lewis operation has been the basis of my own management therapy has not so far fulfilled early expectof these patients. Critics of this operation have ations, but this too must be kept under drawn attention to the risk of oesophagitis constant review. occurring as a conplication. I have not found this to be a serious problem provided the Oesophagitis anastomosis is made high in the chest and Setbacks on the grim battlefields of cancer gastric retention is prevented by carrying out of the oesophagus have led to victories in more rewarding aspects of oesophageal disease. pyloroplasty. A logical development of the Ivor Lewis Not the least of these is the condition which procedure and a great advance is the operation we now know as reflux oesophagitis, a term of subtotal oesophagectomy. This operation, which has been so clearly described and so ably practised by McKeown9, of Darlington, carries the Ivor Lewis procedure one stage further. Following resection of the thoracic oesophagus the stomach is brought right up into the neck, where it is anastomosed to the stump of the cervical oesophagus. The operation has several advantages-growths can be resected even if situated in the upper end of the thoracic oesophagus, and in the case of growths situated lower down any unseen upward extension is included in the resection. Finally, instead of having to make what may be a difficult anastomosis high in the chest a quicker, easier, and safer anastomosis is made in the neck. Contrary to what might be expected patients stand this operation extremely well and I have had one patient of 8o who recovered without any complications. The stage has been reached where the operative mortality has been reduced to a more acceptable level and where palliation is considerable. Recurrences are disappoint- FIG. 2 Oesophageal stricture which proved to ingly frequent but in many cases are not be malignant in spite of its benign appearaccompanied by dysphagia. There is a small ance. (From Annals of the Royal College of group of long-term survivors which has been Surgeons of England, I975, 57, I82.)
The advancing frontiers of oesophageal surgery
suggested by Barrett", which may manifest itself in so many different ways. Great credit is due to Allison" and others, who in I948 focused attention on the sliding hiatus hernia and so brought into line conditions which had previously appeared to be quite disconnected. Early hopes that the problem was entirely an anatomical one and that all the manifestations of reflux oesophagitis could be cured by repair of the hernia proved, however, to be over-sanguine. The interest in the cardiac-sphincter or, as I would prefer to designate it, the cardiac valve was in the first instance anatomical. Pressure studies, measurement of the pH of the oesophageal contents, cineradiography, and improved endoscopy are all throwing light on oesophageal function. It has been shown that sphincter tone is influenced by gastrin and this in turn is modified by antacid therapy. The importance of accurate diagnosis cannot be emphasized too strongly. Gallstones, diverticular disease, and peptic ulceration may all cause confusion, and when duodenal ulceration is present the tendencey to reflux is often accentuated by delay in gastric emptying. If pain is the only symptom a determined course of conservative treatment should be given before surgery is contemplated. The essentials of conservative treatment are weight reduction and the discouragement of reflux by correct posture and by dispensing with abdominal supports. In addition antacids should be given freely. Surgery is indicated if conservative treatment has failed and in those patients who suffer from dysphagia or haemorrhage. If surgery is undertaken for the relief of pain or because of haemorrhage the aim is to control reflux, which can be achieved in several ways. The operations devised by Belsey'3 ', Collis"5, and Nissen'" all give good results if carried out meticulously and in suitable cases. My own preference in general is for Nissen's fundoplication with the addition of pyloro-
plasty. The presence of a 'stricture' introduces an additional complication. In a personal series of some 400 patients who came to operation 40%/O of the men and 33%/ of the women suffered
287
from dysphagia of sufficient severity to require operation. If any degree of fibrosis was present it was considered that a radical procedure was called for and I found that resection with high oesophagogastric anastomosis was a satisfactory procedure. One such patient has been followed up regularly since her operation in I947 and has not shown any evidence of oesophagitis. The need for carrying out such radical procedures has diminished. If reflux can be controlled effectively some of those patients in whom the fibrotic process has been considered to be irreversible can be relieved without any direct attack on the stricture. Furthermore, should the stricture prove to be very severe procedures such as dilatation or local plastic operations may be carried out with confidence provided that reflux is controlled by means of fundoplication. The advances in surgery and anaesthesia have made heroic procedures less hazardousand paradoxically our increasing knowledge of the factors controlling the oesophagus makes some of these procedures unnecessary. References Torek, F (1913) Journal of the American Medical Association, 6o, 1533 2 Turner, G G (1933) Lancet, 2, 13I5. 3 Ohsawa, T (I933) Archiv fiur japanische Chirurgie, 10, 605. 4 Nissen, R (I937) Deutsche Zeitschrift fur Chzrurgie, 249, 3I. 5 Adams, W E, and Phemister, D B (1938) Journal of Thoracic Surgery, 7, 621. 6 Thompson, V C (I945) British Journal of Surgery, 32, 377. 7 Franklin, R H (1942) British Journal of Surgery, 30, 141. 8 Lewis, I (1946) British Journal of Surgery, 34, I8. 9 McKeown, K C (I969) British Medical Association Film No 439. io Franklin, R H (I9'7I) Annals of the Royal College of Surgeons of England, 49, i 65. ii Barrett, N R (1950) British Journal of Surgery, 38, 175. I 2 Allison, P R (1948) Thorax, 3, 20. I3 Belsey, R (I954) Annals of the Royal College of Surgeons of England, 14, 303. 14 Skinner, D B, and Belsey, R H R (I967) Journal of Thoracic and Cardiovascular Surgery, .53, 33. I5 Collis, J L (I968) American Journal of Surgery, I
II5, 465-
i6 Nissen, R, and Rosetti, M (I962) Annales de Chirurgie, i6, 825.
IVOR LEWIS LECTURE, 1975
The advancing frontiers of oesophageal surgery R H Franklin CBE FRCS Past Vice-President, Royal College of Surgeons of England; Honorary Visiting Surgeon, Royal Postgraduate Medical School and Hammersmith Hospital, London.
Introduction Ivor Lewis was born in a 'large upland farm in North Carmarthenshire' in I895 and he spoke only Welsh until he was I 2 years old.
from exploring new ground and in I939 he reported the first successful pulmonary embolectomy in Britain. I am informed that one of his survivors from this operation atHe attended the grammar school at Llandeilo tended the hospital io years later complainuntil the age of i 9, spending the last two years ing of rheumatism. For many years he spent his annual leave on the classical side. He never ceased to be thankful for these two years, which, he writes, 'gave a balance to my future life which most students of medicine today have to go without'. He attributes his choice of medicine as a career to the fact that he had a severe attack of acute appendicitis at the age of I2-being operated upon by David Ellis of Aberystwyth, 'a general practitioner surgeon of the best type'. His education continued-first at Cardiff University and then in London, at University College and University College Hospital. After a number of house appointments he became a surgeon at Lewisham, which was one of the developing London County Council hospitals. Further experience in municipal hospitals was gained in the three years which he spent at the City Hospital in Plymouth as medical superintendent. Here he had charge of a wide range of general surgery. In I933 he was appointed medical director and surgeon at the North Middlesex Hospital and it was here that he made great contributions to surgery. In addition to his administrative duties he had charge of two wards of 30 beds, and these included thoracic as well as general surgical patients. One of his then juniors tells me that he sometimes started a list at 4 p.m. after outpatients and continued until midnight or later. FIG. I Ivor Lewis This heavy work load did not prevent him This inaugural Ivor Lewis Lecture was delivered to the North Middlesex Medical Society on the occasion of the opening of the new Academic Centre by Sir Rodney Smith KBE PRCS on 30th September I975.
The advancing frontiers of oesophageal surgery visiting centres abroad and in 1935 he spent some months in the USA. In addition to his heavy clinical responsibilities and administrative duties he found time to make autopsy studies on the oesophagus. Although he was happy in his busy life in London he never lost the nostalgic wish to return to his homeland. When the National Health Service was born his opportunity came and he found himself appointed by the Welsh Hospital Board to the new hospital development in Rhyl. His surgical career has been more varied and has embraced a wider field than would be possible or even desirable today. But it does support the view of our College that aspirant surgeons should be given a solid foundation of surgical knowledge in general before embarking on a specialty.
The development of oesophageal surgery I am particularly concerned on this occasion with Ivor Lewis's contributions to oesophageal surgery in the I940s. The preceding years had indeed presented a dismal picture. After the first successful resection of the thoracic oesophagus by Torek in 1913I attempts were made all over the world to emulate this triumph, but none succeeded until 1933, when Grey Turner successfully removed the thoracic oesophagus by the 'colloabdominal' or 'pull-through' method2. This somewhat crude procedure was necessitated by the limitations enforced by the equally crude anaesthetics which were available at that time. But it is fitting to pay tribute to the great advances in anaesthesia which did make advances possible. Early attempts at operation were restricted to removing the oesophagus by what was thought to be the least hazardous method. In the unlikely event of the patient recovering from the resection continuity could be restored at a later date. Many and ingenious were the operations devised to this end. The complexity of these procedures arose from the prevalent fear of carrying out an anastomosis within the chest and so risking an intrathoracic leak. Very few of these reconstructions were completed in patients suffering from cancer, and
285
when they were carried out -for benign conditions the development of leaks and strictures was disappointingly frequent. In spite of the appalling mortality a few surgeons persisted in their efforts and the occasional survival or even a near success was heralded as a great surgical achievement. A most important paper by Ohsawa in Japan in I9333 failed to receive the attention it deserved. In the preceding 7 years Ohsawa had been able to resect the lower oesophagus in i8 patients, 8 of whom survived. This was a most remarkable achievement. His success was due to two factors: first, he carried out the operation by means of an abdominothoracic approach; and second, he made an immediate oesophagogastric anastomosis. The importance of the immediate anastomosis was not generally appreciated at first, but Nissen repeated such an operation in I937 on a patient suffering from a benign ulcer'. Successes followed in the United States by Adams and Phemister in I9385 and in Britain by Vernon Thompson in I94,I. These early successes were concerned with growths involving the lower end of the oesophagus and were facilitated by making a leftsided abdominothoracic approach. It was natural that this approach should gain favour and there was some reluctance to abandon it even if the growth extended higher than had been anticipated. If such proved to be the case new difficulties arose. Mobilization of the middle of the oesophagus from the left side of the chest results in opening of the right pleural cavity in most cases and very often damage to the vena azygos, with severe and sometimes uncontrollable haemorrhage. Conversations with the late Mr J H Roberts, of the Brompton and St Bartholomew's Hospitals, gave me the idea of approaching the oesophagus through a right thoracotomy and in 1942 I was able to report two cases in which I had succeeded in resecting the whole of the thoracic oesophagus through the right side of the chest7. The experience of these two successful cases convinced me of the advantages of this approach, but I did not at that time appreciate the importance of making an immediate anastomosis. Ivor Lewis, however, did appreciate both points, and in a masterly Hunterian
286
R H Franklin
Lecture at the Royal College of Surgeons in reported elsewhere'0. In what direction shall we go in the search I9468 he described his operation of first mobilizing the stomach at abdominal laparotomy, for improvement in results? Will earlier then resecting the oesophagus through a right diagnosis achieve this? This may well increase thoracotomy, and in conclusion making an the resection rate, but experience with cancer immediate oesophagogastric anastomosis. I in other sites gives little hope of great improvethink that the detailed description of this pro- ment in long-term survival. Earlier diagnosis cedure constituted a major advance in oeso- is certainly desirable and is aided by cinephageal surgery. To quote his own words, radiography, improved endoscopy, and cyto'the bold early experiments in oesophageal logy, but above all by constant vigilance on surgery were followed by decades spent in try- the part of the doctor. Diagnosis may be ing to circumvent rather than face the dangers, difficult and may need revision (see Figure 2). and recently by a return to straightforward An open mind must be kept as to the value resection with anastomosis'. of X-ray therapy, by itself or in conjunction with surgery and cytotoxic drugs. ImmunoOver the years the Ivor Lewis operation has been the basis of my own management therapy has not so far fulfilled early expectof these patients. Critics of this operation have ations, but this too must be kept under drawn attention to the risk of oesophagitis constant review. occurring as a conplication. I have not found this to be a serious problem provided the Oesophagitis anastomosis is made high in the chest and Setbacks on the grim battlefields of cancer gastric retention is prevented by carrying out of the oesophagus have led to victories in more rewarding aspects of oesophageal disease. pyloroplasty. A logical development of the Ivor Lewis Not the least of these is the condition which procedure and a great advance is the operation we now know as reflux oesophagitis, a term of subtotal oesophagectomy. This operation, which has been so clearly described and so ably practised by McKeown9, of Darlington, carries the Ivor Lewis procedure one stage further. Following resection of the thoracic oesophagus the stomach is brought right up into the neck, where it is anastomosed to the stump of the cervical oesophagus. The operation has several advantages-growths can be resected even if situated in the upper end of the thoracic oesophagus, and in the case of growths situated lower down any unseen upward extension is included in the resection. Finally, instead of having to make what may be a difficult anastomosis high in the chest a quicker, easier, and safer anastomosis is made in the neck. Contrary to what might be expected patients stand this operation extremely well and I have had one patient of 8o who recovered without any complications. The stage has been reached where the operative mortality has been reduced to a more acceptable level and where palliation is considerable. Recurrences are disappoint- FIG. 2 Oesophageal stricture which proved to ingly frequent but in many cases are not be malignant in spite of its benign appearaccompanied by dysphagia. There is a small ance. (From Annals of the Royal College of group of long-term survivors which has been Surgeons of England, I975, 57, I82.)
The advancing frontiers of oesophageal surgery
suggested by Barrett", which may manifest itself in so many different ways. Great credit is due to Allison" and others, who in I948 focused attention on the sliding hiatus hernia and so brought into line conditions which had previously appeared to be quite disconnected. Early hopes that the problem was entirely an anatomical one and that all the manifestations of reflux oesophagitis could be cured by repair of the hernia proved, however, to be over-sanguine. The interest in the cardiac-sphincter or, as I would prefer to designate it, the cardiac valve was in the first instance anatomical. Pressure studies, measurement of the pH of the oesophageal contents, cineradiography, and improved endoscopy are all throwing light on oesophageal function. It has been shown that sphincter tone is influenced by gastrin and this in turn is modified by antacid therapy. The importance of accurate diagnosis cannot be emphasized too strongly. Gallstones, diverticular disease, and peptic ulceration may all cause confusion, and when duodenal ulceration is present the tendencey to reflux is often accentuated by delay in gastric emptying. If pain is the only symptom a determined course of conservative treatment should be given before surgery is contemplated. The essentials of conservative treatment are weight reduction and the discouragement of reflux by correct posture and by dispensing with abdominal supports. In addition antacids should be given freely. Surgery is indicated if conservative treatment has failed and in those patients who suffer from dysphagia or haemorrhage. If surgery is undertaken for the relief of pain or because of haemorrhage the aim is to control reflux, which can be achieved in several ways. The operations devised by Belsey'3 ', Collis"5, and Nissen'" all give good results if carried out meticulously and in suitable cases. My own preference in general is for Nissen's fundoplication with the addition of pyloro-
plasty. The presence of a 'stricture' introduces an additional complication. In a personal series of some 400 patients who came to operation 40%/O of the men and 33%/ of the women suffered
287
from dysphagia of sufficient severity to require operation. If any degree of fibrosis was present it was considered that a radical procedure was called for and I found that resection with high oesophagogastric anastomosis was a satisfactory procedure. One such patient has been followed up regularly since her operation in I947 and has not shown any evidence of oesophagitis. The need for carrying out such radical procedures has diminished. If reflux can be controlled effectively some of those patients in whom the fibrotic process has been considered to be irreversible can be relieved without any direct attack on the stricture. Furthermore, should the stricture prove to be very severe procedures such as dilatation or local plastic operations may be carried out with confidence provided that reflux is controlled by means of fundoplication. The advances in surgery and anaesthesia have made heroic procedures less hazardousand paradoxically our increasing knowledge of the factors controlling the oesophagus makes some of these procedures unnecessary. References Torek, F (1913) Journal of the American Medical Association, 6o, 1533 2 Turner, G G (1933) Lancet, 2, 13I5. 3 Ohsawa, T (I933) Archiv fiur japanische Chirurgie, 10, 605. 4 Nissen, R (I937) Deutsche Zeitschrift fur Chzrurgie, 249, 3I. 5 Adams, W E, and Phemister, D B (1938) Journal of Thoracic Surgery, 7, 621. 6 Thompson, V C (I945) British Journal of Surgery, 32, 377. 7 Franklin, R H (1942) British Journal of Surgery, 30, 141. 8 Lewis, I (1946) British Journal of Surgery, 34, I8. 9 McKeown, K C (I969) British Medical Association Film No 439. io Franklin, R H (I9'7I) Annals of the Royal College of Surgeons of England, 49, i 65. ii Barrett, N R (1950) British Journal of Surgery, 38, 175. I 2 Allison, P R (1948) Thorax, 3, 20. I3 Belsey, R (I954) Annals of the Royal College of Surgeons of England, 14, 303. 14 Skinner, D B, and Belsey, R H R (I967) Journal of Thoracic and Cardiovascular Surgery, .53, 33. I5 Collis, J L (I968) American Journal of Surgery, I
II5, 465-
i6 Nissen, R, and Rosetti, M (I962) Annales de Chirurgie, i6, 825.
