What are the results of esophago-cardiomyotomy for cardiospasm ?
M. Ribet (Lille)
Heller's operation can be performed through an abdominal or a thoracic approach ; its technique is discussed ; its results are inconstant. The myotomy is a treatment not of the cause, but of the effect of an altered function of the cardia and esophagus. Acting against dysphagia, it may provoke other complications and associated procedures have been proposed to prevent them.
Population and methods
From 1958 to 1988 we treated 110 patients, 9 to 72 years old, with a mean age of 45 years for 55 males and of 48 years for 55 females. Five patients were operated twice, 3 after surgery performed elsewhere, 2 after surgery performed in our unit.
Symptoms had lasted from a few months to 20 years and their duration was 2 to 5 years in half the cases. Dysphagia was observed in all the cases and was paradoxal in 20 patients (18 %); 56 patients had food regurgitations (51 %), 14 had pains and heartburns (12%); 2 had hiccough and 2 had hemorrhage. Associated respiratory disorders were observed in 19 patients. Fifty-six patients (51 %) underwent a more than 20 p. cent weight loss.
Radiological examination classified type I (57 cases — 52 %), achalasia with no dilation or with a dilatation inferior to 6 cm in diameter, type II (42 cases — 38 %), dilatation superior to 6 cm in diameter, and type III (11 cases -- 10%), mega-dolicho-esophagus. Esophageal dyskinesia was associated in 26 cases (24 %), a cervico-thoracic diverticulum in 4 cases, a mid-thoracic diverticulum in 1 case and a hiatal hernia in 3 cases.
Esophagoscopy was performed in 72 patients, showing esophagitis in 28 cases (39 %): type I — 16, type II — 9, type III — 3; in 1 case a Barrett's esophagus was observed.
Surgery was performed through coeliotomy in 106 cases and through thoracotomy in 4 cases (including a redo). The technique of myotomy changed during the considered period : from 1958 to 1965, it concerned the esophagus (4-10 cm) and the stomach (3-5 cm); from 1966 to 1975, a pyloroplasty, a pyloromyotomy or a trans-mural digital dilatation of the pylorus ring were associated. Since 1985, we have reduced the dissection of the lower esophagus to its anterior surface and have limited the myotomy to the esophagus and cardia, without cutting into the gastric muscular wall.
Results
Two deaths (1.8 %) occurred in the post-operative period : one from an esophageal perforation, with peritonitis and necroziting ileitis, one from Gram — septicemia in a 40 years old patient who was cachectic, had sclerodermia, arteritis and chronic renal insufficiency. Morbidity (6.3 %) consisted in 4 lung infections, 1 localized mediastinitis, 1 subphrenic abscess and 1 massive reflux, which was cured after 3 months of medical treatment.
Functional results were immediately good for 106 patients (98 %). With a mean follow-up of 5 years, results were good for 40 (50 %): no symptom and gain of weight. They were fair for 26 (32.5 %): intermittent dysphagia and/or regurgitation with gain of weight. They were poor for 14 (17.5%): persistent dysphagia with possibility of gain of weight. Clinical symptoms of reflux had appeared in 7 patients (8.75 %).
A baryum meal was given to 60 patients. The result was considered good in 41 (67 %): normal cardial opening and esophageal diameter, no stasis. It was considered as fair in 14 (23 %): normal cardial opening, unchanged esophageal diameter, no stasis. It was poor in 6 (10 %): narrow cardial passage and/or stasis. A radiological reflux was observed in 9 cases (15%). Endoscopy was performed in 7 patients only, who had persistent symptoms or suffered again after a period of rest: it showed a normal mucosa in 1 case, 4 esophagitis (1 stage I, 1 stage II, 2 stage III) and 2 malignancies.
Discussion
Variations of technique in Heller's operation illustrate three subjects of controversies : 1) the possibility of reflux after esophago-cardiomyotomy and its prevention ; 2) the facilitation of gastric emptying; 3) the effects of myotomy on esophageal motility.
Considering the possibility of post-operative reflux, statistics vary between 3 and 18 p. cent. In our experience, clinical symptoms of reflux appeared in 8.75 p. cent of our patients and radiological signs in 15 p. cent of them. But a pre-operative reflux may exist: the esophageal reaction to reflux may take the appearance of a true cardiospasm.
This aspect of reflux is difficult to study and is sometimes overlooked : 14 of our patients (12%) had heartburns before operation with an evident intermittent reflux in 2 cases only. If a reflux exists, it must be surgically corrected after the myotomy is done. The myotomy itself can also completely suppress the zone of high esophageal pressure and can destroy the attachments of the cardia: the first result is partially aimed at, the second facilitates the myotomy, especially through an abdominal approach. The post-operative reflux is aggravated by the absence of esophageal contractions and by the stasis of its contents. Therefore, an anti-reflux procedure has been proposed.
When we compare 45 patients in our series who were operated before 1975 without such a procedure with 35 patients who were operated after 1975 with a modified Hill's cardiopexy, we observe, in the first group, 36 good and fair results
versus 9 poor results (including 7 cases of reflux); in the second group, we observe 31 good and fair results versus 4 poor results (including 1 case of reflux). In spite of the decrease of cases of reflux in the second group, the difference is not significant: X2 = 1,9. 0,05 < p < 0,1.
Anti-reflux procedures have been accused of hampering the progression by gravity of the alimentary bolus, especially when they are realized by a complete, too tight or too long fundoplication ; a partial fundoplication or a cardiopexy should do better. Another way to prevent reflux would be to perform a myotomy which would be sufficient to cure the cardiospasm, insufficient to completely suppress the zone of high pressure, and which would respect as much as possible the external anatomy of the cardia. It seems that the thoracic approach is consistent with a very low rate of post-operative reflux for these two reasons.
The same advantages can be obtained through the abdominal approach with a hemi-circumferential dissection, limited to the anterior face of the eso-cardial junction. Also to decrease the consequences of post-operative reflux, it has been proposed to associate vagotomy with or without a procedure of gastric emptying facilitation, gastric stasis being considered as a factor of reflux. In 5 of our patients, reflux appeared in spite of a pyloroplasty and we limit this procedure to cases where a vagal nerve is traumatized.
Last, whatever are the modifications brought to the cardia by the myotomy, the post-operative reappearance of esophageal peristaltic waves has not been proved in more than a minority of cases. This explains the absence of correlation between clinical and radiological stages and the possibility of differences between clinical and radiological long term results: radiology does not analyse motricity.
Heller's operation weakens the tonus of the lower esophageal sphincter, but it does not reestablish the esophageal power of efficient contractions.
Conclusions
1) Manometry is to be used more frequently before and after treatment.
2) The surgical thoracic approach is to be considered.
3) Anatomy must not be destroyed, even to be repaired.
4) Myotomy should be limited to the esophagus.
5) If an anti-reflux procedure is added, it should not become an obstacle.
6) Gastric drainage ought to be limited to cases of vagal trauma.
7) After myotomy a triple morbidity is possible : functional, peptic, and malignant.
A perfect technique decreases its rate, but never completely suppresses it. A regular and lasting follow-up is recommendable.