Treatment of Peptic Esophageal Stricture With Combined Fundic Patch-fundoplication (
JOHN 1. HOLLENBECK, M.D., EDWARD R. WOODWARD, M.D.
Forty-five patients treated for peptic esophageal stricture by combined fundic patch-fundoplication are reviewed. The operation afforded an acceptable result in 87% of the patients. There has been no operative mortality. The stricture represents trans-
From the Department of Surgery, College of Medicine, University of Florida, Gainesville, Florida 32610-
mural fibrosis of the distal esophagus. This fibrosis interferes with the physiologic function of the LES preventing receptive relaxation. This, however, does not affect the postoperative ability to swallow.
Material Thirty-four males and 12 females comprise the patient population. They range in age from 3 to 85 years. All' patients in this group had firm, fibrous strictures which' were difficult or impossible to safely dilate. All strictures were a result of gastroesophageal reflux. Three patients in this grou.p have scleroderma and resultant reflux with, stricture formation. Details of two of these patients are presented elsewhere.' Preoperative studies included barium contrast examilnation and esophagoscopy with biopsy. Esophageal motility and pH reflux studies were not generally done because of the difficulty encountered in passing thev catheters into the stomach. Postoperative data for this report were obtained by outpatient clinic visits, inpatient admissions, and telephone or letter contact wtih patients, or their referring physicians. The technique of this procedure is described in an earlier publication.'°
fEPTIC ESOPHAGITIS with esophageal stricture repre'-sents two distinct entities that must be corrected if a long-term, satisfactory result is to be obtained. The strictured esophageal lumen must be enlarged and the associated gastroesophageal reflux prevented. We have combined the fundic patch of Thal9 for correction of the stricture and the Nissen fundoplication5 to prevent reflux. Initially, we used only the Thal patch, but soon found that the patch is susceptible to gastroesophageal reflux and recurrent stricture. This report summarizes our results of the combined Thal-Nissen operation through 1974. In this review we shall also discuss the effect of transmural esophageal fibrosis within the distal esophagus and the physiologic function of the high pressure zone created by the fundoplication.
Results Of the 46 patients in the study group, one patient was Presented at the Annual Meeting of the American Surgical Associalost to followup. Twenty-six patients were followed4 tion, Quebec City, Quebec, May 7-9, 1975. This work has been supported by NIH Grant #AM-13544. longer than 3 years, 5 greater than 2 years, 9 greater than 472
PEPTIC ESOPHAGEAL STRICTURE
Vol. 182 * No. 4
TABLE 3. Complications
TABLE 1. Results-45 Patients
Good
31
(69.0%)
Fair
8
(18%)
Poor
6
(13%)
Mortality Morbidity: Pulmonary infection Pulmonary embolus
87%
one year, and 5 less than one year. We classify our results as good if the patient: 1) can eat any food with minimal or no dysphagia, 2) required no dilatations after the early postoperative period, and 3) has no symptoms of gastroesophageal reflux. Patients who: 1) require occasional dilatation (no more frequently than every three months) or 2) have dysphagia for some foods or 3) have mild reflux symptoms are considered as fair results. Significant dysphagia, need for frequent dilatations or recurrent reflux esophagitis are indicative of a poor result. Thirty-one patients (69o) are classified as good results. Eight of the 45 or 18% are considered fair results and six or 13% have poor results. Thus, 87% of the patients in the study group have acceptable results from their operation (Table 1). The apparent reasons for the poor results are summarized in Table 2. There was no operative mortality in this series. Complications of operation are summarized in Table 3. Postoperative pneumonia occurred in 5 patients and atelectasis occurred in two. One patient was felt to have had a pulmonary embolus. Four patients developed wound infection and one a wound dehiscence. Esophageal leak occurred twice and both times was treated successfully by total parenteral alimentation and chest tube drainage. There were two episodes of cardiac arrhythmias that responded to medication, one patient with prolonged ileus, and one case of acute gastric dilatation. Postoperative esophageal motility studies were obtained in 11 patients. All motility tracings showed normal peristalsis within the body of the esophagus. There was an adequate high pressure zone (HPZ) measuring from 8 to 12 cm of water in all 11 patients studied. However, the created HPZ does not function like the normal lower esophageal sphincter (LES). Deglutition resulted in receptive relaxation within the HPZ in only one of the 11 patients. This contrasts with patients who have had only a Nissen fundoplication. Receptive relaxation is seen in the HPZ of these patients who had no pre-existing stricture. TABLE 2. Apparent Reason for Poor Results
Thal only followed at a later date by Nissen fundoplication Incomplete Nissen fundoplication Malignant stricture Periesophageal scar causing mechanical esophageal obstruction
473
Wound infection Wound dehiscence Esophageal leak Other
0 7 I 4 I 2 4
Discussion The combined Thal-Nissen operation is reserved for patients with firm, fibrous, transmural strictures which cannot be easily or safely dilated. Other reports2 3 state that reflux-induced esophageal strictures can be treated by dilatation or finger fracture combined with an antireflux procedure. We do not agree that this is the case with the transmural stricture because it represents a scar contracture within the wall of the esophagus (Figs. 1 and 2). As with all scars, there is a three dimensional contraction. Esophageal scar decreases the lumen by circumferential contracture and the length is reduced by longitudinal contracture. The loss of length results in an "acquired short esophagus" and this makes the maintenance of the intra-abdominal gastropexy most unsure. Fracture of the stricture disrupts tissue integrity resulting in the formation of granulation tissue which is followed by fibroblast proliferation, collagen deposition and recurrence of the scar. Addition of an anti-reflux procedure following fracture of the stricture will not prevent this biological phenomenon of scar formation. Because peptic esophageal stricture represents a scar contracture, we feel that the fundic patch introduced by Thal represents the operation of choice for esophageal stricture. The patch provides tissue with an excellent blood supply which is easily transferrable to the stricture site. This allows replacement of the tissue loss by scar contraction with pliable, well-vascularized tissue. We have earlier reported1' that the Thal patch is subject to injury from esophageal reflux if unaccompanied by an anti-reflux procedure. Four of 5 patients who had the Thal patch alone developed recurrent stricture from persistent gastroesophageal reflux. We, therefore, feel the anti-reflux component is mandatory and the Nissen fundoplication has proven its effectiveness. In those patients who have undergone previous gastric surgery or have a long stricture, there may not be enough fundus to perform a complete wrap. This has been the case in approximately 15% of the procedures in our series. We have employed either 2 partial Nissen wrap or the Belsey7 type anti-reflux proce2 dure in these patients. Although the number of cases is I small, we seem to be obtaining better results with the Belsey maneuver than the partial Nissen wrap. I The complete Nissen wrap does restore a distal high
474
HOLLENBECK ANI) W)ODWARD
St,,-9.
Alli.
Fi(i.
1.
* ( ).oher- 19J75
Biopsy
of
an
esophageal stricture demonstrating fibrous tissue (f) within the musculature q.94Fg (m) (H + E original magnification x 100).
pressure zone within the esophagus. The mechanism by which this occurs is currently being debated. Lipshutz. et
al.4 have shown that the Hill posterior gastropexy and the Belsey Mark IV repair restore resting lower esophageal
sphincter tone along with a normal response to mechanical and neurohumoral stimulation. Intravenous pentagastrin administration produces contraction of the LES in these patients. They suggest return of normal resting tone ~
U.
j ^^ /;
_
F(i;. 2. Biopsy in the region of the lower esophageal sphincter demonstrating infiltration of muscle (m) by fibrous tissue (f) in a patient with reflux-induced esophageal stricture (Masson trichrome
tion
original magnifica-
x440).
475
PEPTIC ESOPHAGEAL STRICTURE
\,(I. 1X2* N.). 4
POSTOP THAL- NISSEN
POSTOP NISSEN FUNDOPLICATION
30 cm
31 cm
35 cm 40 cm
..L ES
36 cm
.
41 cm
LES' PNEUMOGRAPH PNEU MOGR APH
SWALLOW
SWALLOW
FIG. 3. Esophageal motility tracing of a patient following Nissen fundoplication demonstrating receptive relaxation of the lower esophageal sphincter during deglutition.
Fi(;. 4. Esophageal motility tracing of a patient following the ThalNissen procedure showing there is no receptive relaxation of the lower esophageal sphincter with deglutition.
optimizes the length-tension characteristics of the lower esophageal sphincter muscle allowing it to function physiologically. Others,1'8 have disagreed with their conclusions. We have found that the Nissen fundoplication restores resting lower esophageal sphincter pressure while the physiologic characteristic of receptive relaxation of the LES remains intact (Fig. 3). However, 10 of I I patients following a Thal-Nissen repair of esophageal strictures do not demonstrate this (Fig. 4). This may be attributed to the longitudinal incision made in the esophagus at the LES while doing the Thal portion of the repair. However, we believe that the LES does not have normal characteristics in these patients due to the transmural involvement of the LES by fibrosis. The fibrous tissue prevents the LES from responding properly to physiologic stimuli. The incidence of carcinoma is low in peptic stricture of the esophagus, but it does occur. We have one such patient in our series. This patient had a 35-year history of symptomatic reflux esophagitis. Endoscopic biopsies were interpreted as showing only acute and chronic esophagitis. However, a small portion of the stricture sent for permanent section at operation showed carcinoma. Because of this experience we strongly recommend intraoperative biopsy of the stricture and frozen section pathologic examination. It is interesting to note that 8 of the 46 patients ( 17%) in this series developed symptoms of dysphagia subsequent to nasogastric intubation for other procedures. In all 8, symptoms of dysphagia developed within 2 weeks to 4 months following nasogastric intubation even though the intubation lasted as short as 12 hours. This points out a
need for a careful history of gastroesophageal reflux in any patient who will require an indwelling nasogastric tube. If postoperative gastric decompression is planned in a patient with gastroesophageal reflux symptoms, a temporary gastrostomy should be considered. References 1. Grossman, M. I.: Letter to the Editor: Restoration of Loweresophageal-Sphincter Function by Operation. N. Engl. J. Med.. 292:316, 1975. 2. Herrington, L., Wright, R. S.. Edwards, W. H. and Sawyers, J. L.: Conservative Surgical Management of Reflux Esophagitis and Esophageal Stricture. Ann. Surg., In press. 3. Hill, L. D., Gelfand, M. and Bauermeister, D.: Simplified Management of Reflux Esophagitis with Stricture. Ann. Surg., 172:638, 1970. 4. Lipshutz, W. H., Eckert, R. J.. Gaskins, R. D., et al.: Normal Lower-Esophageal-Sphincter Function after Surgical Treatment of Gastroesophageal Reflux. N. Engl. J. Med., 291:1107, 1974. 5. Nissen, R.: The Treatment of Hiatal Hernia and Esophageal Reflux by Fundoplication. In Hernia, Edited by L. M. Nyhus and H. S. Harkins, Philadelphia, Lippincott, 1964. 6. O'Leary, J. P., Hollenbeck, J. I. and Woodward, E. R.: Surgical Treatment of Esophageal Stricture in Patients with Scieroderma. Am. Surg., 41:131, 1975. 7. Skinner, D. B. and Belsey, R. H.: Surgical Management of Esophageal Reflux and Hiatus Hernia. J. Thoraco Cardiovasc. Surg., 53:33, 1967. 8. Stark. P.: Letter to the Editor: Restoration of Lower-EsophagealSphincter Function by Operation. N. Engl. J. Med., 292:317, 1975. 9. Thai, A. P., Hatafuku, T. and Kurtzman. R.: New Operation for Distal Esophageal Stricture. Arch. Surg., 90:464, 1965. 10. Thomas, H. F., Clarke, J. M., Rayl, J. E. and Woodward, E. R.: Results of the Combined Fundic Patch-Fundoplication Operation in the Treatment of Reflux Esophagitis with Stricture. Surg.
Gynecol. Obstet. 135:241, 1972.
11. Woodward, E. R., Rayl, J. E. and Clarke. J. M.: Esophageal Hiatus Hernia. (monograph). Current Problems in Surgery, Chicago. III., Year Book Medical Publishers. Inc.. December, 1970.
JOHN 1. HOLLENBECK, M.D., EDWARD R. WOODWARD, M.D.
Forty-five patients treated for peptic esophageal stricture by combined fundic patch-fundoplication are reviewed. The operation afforded an acceptable result in 87% of the patients. There has been no operative mortality. The stricture represents trans-
From the Department of Surgery, College of Medicine, University of Florida, Gainesville, Florida 32610-
mural fibrosis of the distal esophagus. This fibrosis interferes with the physiologic function of the LES preventing receptive relaxation. This, however, does not affect the postoperative ability to swallow.
Material Thirty-four males and 12 females comprise the patient population. They range in age from 3 to 85 years. All' patients in this group had firm, fibrous strictures which' were difficult or impossible to safely dilate. All strictures were a result of gastroesophageal reflux. Three patients in this grou.p have scleroderma and resultant reflux with, stricture formation. Details of two of these patients are presented elsewhere.' Preoperative studies included barium contrast examilnation and esophagoscopy with biopsy. Esophageal motility and pH reflux studies were not generally done because of the difficulty encountered in passing thev catheters into the stomach. Postoperative data for this report were obtained by outpatient clinic visits, inpatient admissions, and telephone or letter contact wtih patients, or their referring physicians. The technique of this procedure is described in an earlier publication.'°
fEPTIC ESOPHAGITIS with esophageal stricture repre'-sents two distinct entities that must be corrected if a long-term, satisfactory result is to be obtained. The strictured esophageal lumen must be enlarged and the associated gastroesophageal reflux prevented. We have combined the fundic patch of Thal9 for correction of the stricture and the Nissen fundoplication5 to prevent reflux. Initially, we used only the Thal patch, but soon found that the patch is susceptible to gastroesophageal reflux and recurrent stricture. This report summarizes our results of the combined Thal-Nissen operation through 1974. In this review we shall also discuss the effect of transmural esophageal fibrosis within the distal esophagus and the physiologic function of the high pressure zone created by the fundoplication.
Results Of the 46 patients in the study group, one patient was Presented at the Annual Meeting of the American Surgical Associalost to followup. Twenty-six patients were followed4 tion, Quebec City, Quebec, May 7-9, 1975. This work has been supported by NIH Grant #AM-13544. longer than 3 years, 5 greater than 2 years, 9 greater than 472
PEPTIC ESOPHAGEAL STRICTURE
Vol. 182 * No. 4
TABLE 3. Complications
TABLE 1. Results-45 Patients
Good
31
(69.0%)
Fair
8
(18%)
Poor
6
(13%)
Mortality Morbidity: Pulmonary infection Pulmonary embolus
87%
one year, and 5 less than one year. We classify our results as good if the patient: 1) can eat any food with minimal or no dysphagia, 2) required no dilatations after the early postoperative period, and 3) has no symptoms of gastroesophageal reflux. Patients who: 1) require occasional dilatation (no more frequently than every three months) or 2) have dysphagia for some foods or 3) have mild reflux symptoms are considered as fair results. Significant dysphagia, need for frequent dilatations or recurrent reflux esophagitis are indicative of a poor result. Thirty-one patients (69o) are classified as good results. Eight of the 45 or 18% are considered fair results and six or 13% have poor results. Thus, 87% of the patients in the study group have acceptable results from their operation (Table 1). The apparent reasons for the poor results are summarized in Table 2. There was no operative mortality in this series. Complications of operation are summarized in Table 3. Postoperative pneumonia occurred in 5 patients and atelectasis occurred in two. One patient was felt to have had a pulmonary embolus. Four patients developed wound infection and one a wound dehiscence. Esophageal leak occurred twice and both times was treated successfully by total parenteral alimentation and chest tube drainage. There were two episodes of cardiac arrhythmias that responded to medication, one patient with prolonged ileus, and one case of acute gastric dilatation. Postoperative esophageal motility studies were obtained in 11 patients. All motility tracings showed normal peristalsis within the body of the esophagus. There was an adequate high pressure zone (HPZ) measuring from 8 to 12 cm of water in all 11 patients studied. However, the created HPZ does not function like the normal lower esophageal sphincter (LES). Deglutition resulted in receptive relaxation within the HPZ in only one of the 11 patients. This contrasts with patients who have had only a Nissen fundoplication. Receptive relaxation is seen in the HPZ of these patients who had no pre-existing stricture. TABLE 2. Apparent Reason for Poor Results
Thal only followed at a later date by Nissen fundoplication Incomplete Nissen fundoplication Malignant stricture Periesophageal scar causing mechanical esophageal obstruction
473
Wound infection Wound dehiscence Esophageal leak Other
0 7 I 4 I 2 4
Discussion The combined Thal-Nissen operation is reserved for patients with firm, fibrous, transmural strictures which cannot be easily or safely dilated. Other reports2 3 state that reflux-induced esophageal strictures can be treated by dilatation or finger fracture combined with an antireflux procedure. We do not agree that this is the case with the transmural stricture because it represents a scar contracture within the wall of the esophagus (Figs. 1 and 2). As with all scars, there is a three dimensional contraction. Esophageal scar decreases the lumen by circumferential contracture and the length is reduced by longitudinal contracture. The loss of length results in an "acquired short esophagus" and this makes the maintenance of the intra-abdominal gastropexy most unsure. Fracture of the stricture disrupts tissue integrity resulting in the formation of granulation tissue which is followed by fibroblast proliferation, collagen deposition and recurrence of the scar. Addition of an anti-reflux procedure following fracture of the stricture will not prevent this biological phenomenon of scar formation. Because peptic esophageal stricture represents a scar contracture, we feel that the fundic patch introduced by Thal represents the operation of choice for esophageal stricture. The patch provides tissue with an excellent blood supply which is easily transferrable to the stricture site. This allows replacement of the tissue loss by scar contraction with pliable, well-vascularized tissue. We have earlier reported1' that the Thal patch is subject to injury from esophageal reflux if unaccompanied by an anti-reflux procedure. Four of 5 patients who had the Thal patch alone developed recurrent stricture from persistent gastroesophageal reflux. We, therefore, feel the anti-reflux component is mandatory and the Nissen fundoplication has proven its effectiveness. In those patients who have undergone previous gastric surgery or have a long stricture, there may not be enough fundus to perform a complete wrap. This has been the case in approximately 15% of the procedures in our series. We have employed either 2 partial Nissen wrap or the Belsey7 type anti-reflux proce2 dure in these patients. Although the number of cases is I small, we seem to be obtaining better results with the Belsey maneuver than the partial Nissen wrap. I The complete Nissen wrap does restore a distal high
474
HOLLENBECK ANI) W)ODWARD
St,,-9.
Alli.
Fi(i.
1.
* ( ).oher- 19J75
Biopsy
of
an
esophageal stricture demonstrating fibrous tissue (f) within the musculature q.94Fg (m) (H + E original magnification x 100).
pressure zone within the esophagus. The mechanism by which this occurs is currently being debated. Lipshutz. et
al.4 have shown that the Hill posterior gastropexy and the Belsey Mark IV repair restore resting lower esophageal
sphincter tone along with a normal response to mechanical and neurohumoral stimulation. Intravenous pentagastrin administration produces contraction of the LES in these patients. They suggest return of normal resting tone ~
U.
j ^^ /;
_
F(i;. 2. Biopsy in the region of the lower esophageal sphincter demonstrating infiltration of muscle (m) by fibrous tissue (f) in a patient with reflux-induced esophageal stricture (Masson trichrome
tion
original magnifica-
x440).
475
PEPTIC ESOPHAGEAL STRICTURE
\,(I. 1X2* N.). 4
POSTOP THAL- NISSEN
POSTOP NISSEN FUNDOPLICATION
30 cm
31 cm
35 cm 40 cm
..L ES
36 cm
.
41 cm
LES' PNEUMOGRAPH PNEU MOGR APH
SWALLOW
SWALLOW
FIG. 3. Esophageal motility tracing of a patient following Nissen fundoplication demonstrating receptive relaxation of the lower esophageal sphincter during deglutition.
Fi(;. 4. Esophageal motility tracing of a patient following the ThalNissen procedure showing there is no receptive relaxation of the lower esophageal sphincter with deglutition.
optimizes the length-tension characteristics of the lower esophageal sphincter muscle allowing it to function physiologically. Others,1'8 have disagreed with their conclusions. We have found that the Nissen fundoplication restores resting lower esophageal sphincter pressure while the physiologic characteristic of receptive relaxation of the LES remains intact (Fig. 3). However, 10 of I I patients following a Thal-Nissen repair of esophageal strictures do not demonstrate this (Fig. 4). This may be attributed to the longitudinal incision made in the esophagus at the LES while doing the Thal portion of the repair. However, we believe that the LES does not have normal characteristics in these patients due to the transmural involvement of the LES by fibrosis. The fibrous tissue prevents the LES from responding properly to physiologic stimuli. The incidence of carcinoma is low in peptic stricture of the esophagus, but it does occur. We have one such patient in our series. This patient had a 35-year history of symptomatic reflux esophagitis. Endoscopic biopsies were interpreted as showing only acute and chronic esophagitis. However, a small portion of the stricture sent for permanent section at operation showed carcinoma. Because of this experience we strongly recommend intraoperative biopsy of the stricture and frozen section pathologic examination. It is interesting to note that 8 of the 46 patients ( 17%) in this series developed symptoms of dysphagia subsequent to nasogastric intubation for other procedures. In all 8, symptoms of dysphagia developed within 2 weeks to 4 months following nasogastric intubation even though the intubation lasted as short as 12 hours. This points out a
need for a careful history of gastroesophageal reflux in any patient who will require an indwelling nasogastric tube. If postoperative gastric decompression is planned in a patient with gastroesophageal reflux symptoms, a temporary gastrostomy should be considered. References 1. Grossman, M. I.: Letter to the Editor: Restoration of Loweresophageal-Sphincter Function by Operation. N. Engl. J. Med.. 292:316, 1975. 2. Herrington, L., Wright, R. S.. Edwards, W. H. and Sawyers, J. L.: Conservative Surgical Management of Reflux Esophagitis and Esophageal Stricture. Ann. Surg., In press. 3. Hill, L. D., Gelfand, M. and Bauermeister, D.: Simplified Management of Reflux Esophagitis with Stricture. Ann. Surg., 172:638, 1970. 4. Lipshutz, W. H., Eckert, R. J.. Gaskins, R. D., et al.: Normal Lower-Esophageal-Sphincter Function after Surgical Treatment of Gastroesophageal Reflux. N. Engl. J. Med., 291:1107, 1974. 5. Nissen, R.: The Treatment of Hiatal Hernia and Esophageal Reflux by Fundoplication. In Hernia, Edited by L. M. Nyhus and H. S. Harkins, Philadelphia, Lippincott, 1964. 6. O'Leary, J. P., Hollenbeck, J. I. and Woodward, E. R.: Surgical Treatment of Esophageal Stricture in Patients with Scieroderma. Am. Surg., 41:131, 1975. 7. Skinner, D. B. and Belsey, R. H.: Surgical Management of Esophageal Reflux and Hiatus Hernia. J. Thoraco Cardiovasc. Surg., 53:33, 1967. 8. Stark. P.: Letter to the Editor: Restoration of Lower-EsophagealSphincter Function by Operation. N. Engl. J. Med., 292:317, 1975. 9. Thai, A. P., Hatafuku, T. and Kurtzman. R.: New Operation for Distal Esophageal Stricture. Arch. Surg., 90:464, 1965. 10. Thomas, H. F., Clarke, J. M., Rayl, J. E. and Woodward, E. R.: Results of the Combined Fundic Patch-Fundoplication Operation in the Treatment of Reflux Esophagitis with Stricture. Surg.
Gynecol. Obstet. 135:241, 1972.
11. Woodward, E. R., Rayl, J. E. and Clarke. J. M.: Esophageal Hiatus Hernia. (monograph). Current Problems in Surgery, Chicago. III., Year Book Medical Publishers. Inc.. December, 1970.
