Heller's Myotomy for Achalasia: Is an Added Anti-Reflux Procedure Necessary?
Total Page：16
File Type：pdf, Size：1020Kb
Review Br. J. Surg. 1987, Vol. 74, September, 765-769 Heller's myotomy for achalasia: is an added anti-reflux procedure necessary? Literature review (1970-85) indicates excellent or good results following Heller's operation in 89 per cent of 5002 patients. The overall mortality N. A. Andreollo and was 2-8 per cent with a reoperation rate of 2-8 per cent. When the R. J. Earlam operation was done through an abdominal incision, gastro-oesophageal reflux was almost twice as common as when it was done through a The London Hospital, Whitechapel, London El IBB, UK thoracic incision, regardless of whether an anti-reflux procedure was Correspondence to: performed. Mr R. J. Earlam Keywords: Achalasia, Heller's myotomy Achalasia is due to decreased numbers or absence of ganglion Review of the literature cells in Auerbach's plexus between the inner circular and outer 6 longitudinal muscle layers. In the normal oesophagus there are A review in 1980 reported 4500 patients , whereas previously almost no nerve cells in the submucous Meissner's plexus so the situation was summed up by Ellis and Olsen in their classic 1969 monograph based on 1906 patients2. The present paper is that a mucosal biopsy is useless for diagnosis. The physiological 7 81 abnormalities are: absent peristalsis in the body of the based on 5002 patients reported in 75 papers " (Table J). oesophagus and abnormal relaxation in the gastro-oesophageal Some papers with incomplete data have been excluded but the sphincter, which never amounts to a total absence of number cited represents some 90 per cent of all the cited relaxation—achalasia—but only to incomplete relaxation and literature from 1970 to 1985. not always in response to every swallow. The oesophagus fills up with food and fluid leaving the contents to trickle into the Diagnosis stomach under the influence of simultaneous contraction waves The diagnosis of achalasia may be made by analysing clinical and gravity. The air that accompanies a normal bolus does not symptoms, radiology, cineradiography and oesophageal enter the stomach and an absent gastric air bubble is diagnostic. manometry82. Although manometry and oesophageal pressure The resting pressure in the smooth muscle sphincter is either studies are important and essential according to some22'26'28'56, normal, as measured by non-perfused open tip manometry, or they have been employed in only 5 per cent of the series above normal if perfused. This perfused pressure is the preferred reported13-23-26-28-30-33-45'55-56-58-60'62'76. Oesophagoscopy methodology now and represents a squeeze response to pressure was used in I2percent10'13-14-17-18-21-28'33-46'51'60-71-75-81. increments caused by the perfused fluid in the sphincter. It is the Other tests such as acid perfusion and pH measure- manometric equivalent to cardiospasm which is often used as a 13 15 19 30 62 51 1 ments - ' - - , cineradiography and pharmacological synonym for achalasia—the Greek word for failure to relax . tests (mecholyl)34 were rarely used. Of specific relevance to the The treatment for achalasia is based on the principle that present study, the associated abnormalities of hiatus hernia there is an abnormal sphincter which causes obstruction, and (0-5 per cent)14-57 and peptic ulcer (<0-3 per cent) were rarely that weakening, but not destroying it completely, improves found pre-operatively. Approximately 43 per cent of the patients oesphageal emptying even though the underlying pathology reported had been dilated before being submitted to definitive itself cannot be changed. Dilatation of the lower oesophagus surgery 10.13,27,28.34.51,58 and its treatment by a whalebone probang were described by Willis in 16722'3. The first successful surgical procedure was performed by a German surgeon, Ernest Heller, on 14 April 1913 Surgery through a laparotomy and consisted of a double myotomy4. Since the first Heller's myotomy in 1913 and Zaaijer's Zaaijer, a Dutch surgeon, modified this by using a single modification in 1923, both by the abdominal approach, myotomy incision in 19235. The weakening of the numerous different procedures have been introduced. In this gastro-oesophageal sphincter by a single incision approach review 56 per cent of the patients had the myotomy done through the abdomen or chest is the present surgical procedure through a thoracotomy. Some authors employed both the of choice. There are two main complications: recurrent thoracic and abdominal approach37-73. The different anti-reflux dysphagia due to an incomplete myotomy and gastro- procedures with reference to the authors using either a thoracic oesophageal reflux. In the last 15 years there has been an or abdominal approach are listed in Table 2. increased number of reports of reflux after a Heller's myotomy Associated procedures such as proximal gastric vagotomy30, and many authors have advocated the routine addition of an truncal vagotomy63 and pyloroplasty17-31-37-54-63 have also anti-reflux procedure. In spite of this, the majority still do a been used. Other authors have proposed a complete incision simple myotomy and obtain good results. The purpose of this through the oesophageal wall and reconstitution of the article is to review the recent literature to see whether there was oesophagogastric junction with the gastric fundus37-63-70-83 or any reason to add the anti-reflux procedure, whether its Y-V cardioplasty37. Approximately 50 per cent of the patients necessity was due to a different technique of making the cut in had an added anti-reflux operation. The mark IV Belsey repair the muscle which destroyed rather than weakened the sphincter, was the most widely used anti-reflux procedure by thoracic and why some surgeons have good results with a simple surgeons (21 per cent) and the anterior fundoplication was myotomy and very little subsequent gastro-oesophageal reflux. mostly employed by abdominal surgeons (36 per cent). 0007-1323/87/090765-05$3.00 CO 1987 Butterworth & Co (Publishers) Ltd 765 . Heller's myotomy: N. A. Andreollo and R. J. Earlam Table 1 Collected data from 75 papers (1970-85) Patients Sex Mean Results (%) age Anti-reflux Deaths (excellent Reflux First author Year Country n Male Female (years) Approach* procedure (%) and good) ( °/1 Reoperations Adebo7 1980 Nigeria 36 25 11 34-5 T 2-8 94 6 2 Akuamoa8 1971 Denmark 101 61 40 40 A — 91-5 8-5 Anyanwu9 1982 Nigeria 30 21 9 36-6 T — 96-3 0 Arvanitakis10 1975 USA 23 14 9 54-4 T — 91 0 Barker1 ' 1971 England 30 15 15 41 T — 90 16-6 3 Belsey12 1972 England 149 T + 1-3 90 16 Bjorck13 1982 Sweden 63 29 34 43 T — 88 12-6 Black14 1976 England 108 56 52 47-5 A + — 65-5 18-5 4 Borgeskov15 1970 Denmark 52 24 28 42 T — 75 15 3 Boulez16 1981 France 103 A 95 17-5 Cabrero-Gomez17 1982 Spain 50 19 31 40 A + — 86-4 6 5 Caminiti18 1975 Italy 27 58 T 88 7-4 Castrini19 1982 Italy 40 27 13 44 T — 95 2-7 2 Coan20 1971 Italy 21 10 11 35 T + — 90 Coloni21 1975 Italy 124 T — 87-6 6-4 Csendes22 1975 Chile 20 11 9 45-2 A + 95 0 De La F. Perucho23 1977 Spain 45 20 25 32-8 A + — 78-5 Dotsenko24 1973 Ethiopia 17 30 T + — 90 Dotsenko25 1984 Russia 52 18 34 T + — 95 5 Duranceau26 1982 Canada 12 6 6 44 T + 95 0 Effler27 1971 USA 100 35 65 12-74 T + 87 3 4 Ellis28 1984 USA 113 49 64 45 T 94 3-5 Fekete29 1977 France 370 A + — 85 55 Gallone30 1982 Italy 14 8 6 45 A + — 95 0 Gavriliu31 1975 Romania 256 A + 84-1 Giovinetto32 1978 Italy 24 A + — 87-5 12-5 Goulbourne33 1985 Scotland 65 33 32 40 T — 80 4-6 Grimes34 1970 USA 50 47 T — 78 6 Harley35 1976 Wales 65 T 96-5 35-2 Heil36 1980 Germany 13 A + — 100 Hirashima37 1978 Japan 21 A — 80 Hollender38 1977 France 22 A + 90 10 Jamieson39 1984 Canada 36 18 18 T + — 95 2-7 4 Jara40 1979 USA 145 57 88 40-60 T 89 24 9 Jezioro41 1977 Poland 21 A + 90 9-5 Kessler42 1980 Germany 49 A + 2 90 0 Kinoshita43 1981 Japan 19 A + — 73 Lagache44 1970 France 53 — — 90 5-6 Lens45 1980 Holland 12 8 4 T + — 100 0 Mabogunje46 1983 Nigeria 20 11 9 20-40 A — 80 5 Maillet47 1973 France 72 A + — 96 Mansour48 1976 USA 38 T — 80 23-6 Mehta49 1974 India 75 42 33 T - 1-3 86-7 8 Menguy50 1971 USA 6 A + — 100 Menzies-Gow51 1978 England 102 51 51 45 T — 80 13-7 5 Moreno G-Bueno52 1981 Spain 64 30 34 A + — 94-2 5-8 Mullard53 1972 England 100 j — 96 7 Muralidharam54 1978 India 90 60 30 T 1-1 92-3 3-1 Murray55 1984 USA 21 12 9 8-74 T + — 95 0 Nelems56 1980 Canada 32 46 T + — 90 12-5 14 Nemir57 1971 USA 74 T 1-35 75 17-5 11 Okike58 1979 USA 468 220 248 51 T 94 3 3 Orringer59 1976 USA 3 T + — 100 Pai60 1984 USA 36 18 18 43 T + 2-8 94 11-1 4 Petrovsky61 1972 Russia 113 T + 79-7 7-1 Peyton62 1974 USA 14 8 6 T + — 80 29 Rees63 1971 USA 84 50 34 48-4 T + — 90 8-3 6 Ribet64 1975 France 75 A + — 79 14 Rossetti65 1978 Switzerland 63 A + 95 Ruland66 1981 Germany 57 90 9-8 Sariyannis67 1975 England 48 17 31 50-7 T — 95-8 8-3 3 Schomacher68 1978 Germany 25 12 13 42 A + — 95 Sery69 1982 Poland 204 A + — 85 Shevchuk70 1983 Russia 31 A + — 95 6-4 Stein71 1985 Zimbabwe 25 — 90 Stipa72 1976 Italy 162 A — 85 22 Tomlinson73 1981 Australia 74 29 45 48 T + 1-4 91-4 8-5 Uchida74 1981 Japan 20 T + 95 Veiga-Fernandes75 1981 Portugal 15 A + 100 0 76 — Viard 1983 France 90 40 50 A + — 87-6 11 4 Vossschulte77 1972 France 19 A 100 Yon78 1975 USA 24 40-50 T - 85 20-8 766 Br.