What thoughts these names conjure up. and how tempting it would be to give an. account of some of my distinguished predecessors!

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1 Annals of the Royail College of Surgeons of England (1975) vol 57 0Oesophageal surgery R H Franklin CBE FRCS Vice-President, Royal College Postgraduate Medical School of Surgeons of England; Honorary Visiting and Hammersmith Hospital, London Surgeon, Royal Summary A wide variety of benign conditions affecting the oesophagus which have long been recognized in association with hiatus hernia are now known to be attributable to reflux oesophagitis. The development of modern methods of treatment of these conditions is described with reference to a number of illustrative cases. Introduction William Wood Bradshaw was born in Bristol in i8oi. He received his medical education at Westminster Hospital and he practised first at Andover and later at Reading. He has been described as a 'quiet, homeloving, and studious man' who 'diligently cultivated his mind both in literature and science'. He was one of the first surgeons to be elected to the Fellowship of our College as a member of 15 years standing in accordance with the regulations which were in force at that time. This lecture was endowed by his widow in I88-4 years after his death -and she endowed a similar eponymous lecture at the Royal College of Physicians. The first lecture was delivered by Sir James Paget on i3th December I882, and in the years that follow we see such names as Lister, Spencer Wells, Butlin, Bland Sutton, and Moynihan, to mention only a few. Bradshaw Lecture delivered oi1 12th December, 1973 What thoughts these names conjure up and how tempting it would be to give an account of some of my distinguished predecessors! This, however, is not to be, for it has become customary for the Bradshaw Lecturer to talk about a subject which has been of particular interest to him during his surgical life. My long association with Grey Turner and the interest in the oesophagus which he inculcated makes this a natural choice for me. He delivered the Bradshaw Lecture in I935, his subject being carcinoma of the oesophagus. I feel that a fitting sequel to his lecture is a consideration of the condition which we now know as reflux oesophagitis. An additional reason for selecting this subject is that the advances which have been made in the surgery of benign oesophageal conditions are due in no small measure to the experience gained in the heroic and hazardous operations which have been carried out in the past for cancer. Historical survey Over the years there have been reports of all sorts of benign conditions affecting the oesophagus. Peptic ulcers arising in so-called ectopic islets of gastric mucosa, strictures in infants with a short oesophagus, strictures associated with pregnancy, anaemia apparently related to diaphragmatic hernia-all

2 I76 R II Frantiklint these apparently disconnected conditions were described accurately by such authorities as Hill', Hume', Vinson3, and Kelly4. In spite of the number of reports and the great span of years which they covered, no common factor which linked them together was found until the I940s. This confusion existed because of the great variety of signs and symptoms which may be produced by the condition which we now know as reflux oesophagitis. It is clear now that this condition may give rise to pain, haemorrhage, and dysphagia and that any of these may occur singly or in any combination and in all degrees of severity, from the trivial to the very serious. It is not surprising, therefore, that the clinical picture has been so diverse and confusing. A great shaft of light was directed on to the scene in I948 by Allison5, who described accurately the superficial ulceration which starts at the lower end of the oesophagus in association with certain types of hiatus hernia and which he referred to as 'peptic oesophagitis'. Allison's emphasis on the disturbance of the cardiac sphincter by the sliding hernia led to renewed investigations into the anatomy of this mechanism. The anatomical features which appeared to be of most importance were the angle of insertion of the oesophagus into the stomach and the abdominal position of the cardia and lower oesophagus. If these two features were present any increase in abdomitnal pressure would tend to close the lower end of the gullet. The management of these patients now seemed to be quite straightforward-replace the cardia in the abdomen and repair the hernia and all would be well. This conception of a clearcut cause and effect proved to be an oversimplification of the problem. The immediate result, however, was to shed light on an obscure subject and so point the way to further advances. Further evidence of the importance of the cardiac sphincter was brought to light in a paper which Barrett and I published in I949g. We had each independently come to the conclusion, erroneously as it proved, that Heller's operation was not a satisfactory procedure for the relief of achalasia. In order to improve these results Barrett carried out oesophagogastrostomy and I elected to do a cardioplasty. The immediate results were most gratifying; in every case swallowing was restored. It was only later, when we reviewed our respective patients together, that we discovered that almost all of them were suffering from some degree of oesophagitis. Our operations had effectively destroyed the cardiac sphincter. In a further paper in 1950 Barrett7 drew attention to a condition in which the oesophagus appears to be normal but is in fact lined with gastric mucosa which extends upwards from the stomach. This condition is congenital and is quite different from the state of affairs in which a cone of stomach is drawn up into the chest as the result of oesophagitis. Barrett's gastric-lined oesophagus remains symptomless so long as the cardiac sphincter is effective. In this paper Barrett coined the term 'reflux oesophagitis', which he considered was the most suitable way in which to designate the ulceration described by Allison. This term became generally accepted and did much to remove misunderstandings in nomenclature. As a result of Allison's work a great number of hernia repairs were carried out during the next few years. There were differences of opinion as to the indications for operation. Most surgeons agreed then, as they do now, that haemorrhage or stricture formation called for an operation, as does the less common type of hernia, known then as paraoesophageal, in which there is a real

3 risk of strangulation. Where pain was the only symptom there was some disagreement; some surgeons believed that operation should be advised to forestall any subsequent complication such as haemorrhage or stricture formation. My own view was then, and still is, that these patients should be given a trial of a conservative regimen before operation is advised. The early enthusiasm for the repair of the hernia was followed by a period of disenchantment as unsatisfactory results gradually accumulated. Some of the failures were tundoubtedly due to an inadequate repair or to recurrence of the hernia. But in some reflux persisted even though no hernia could be demonstrated. In yet other patients the hernia was complicated by another factor such as peptic ulceration or biliary disease which had been overlooked (Table I). To TABLE I Associated conditions in I67 patients operated on for hiatus hernia Duodenal ulcer Gastric ulcer Gastric and duodenal ulcer Scleroderma of oesophagus Leiomyoma of oesophagus Duodenal ilcus Hypernephroma Carcinoma of jcjuiutn Gallbladder disease discovered at operation Previous cholecygtectomy Subsequent cholecystectomy Io 2 complicate the picture still further it became apparent that a considerable number of people might have a demonstrable hernia and yet be free from symptoms. In an attempt to improve the results of hernial repair-or even in some cases to obviate the need for it-i tried various measures to reduce gastric acidity and to encourage gastric emptying. This approach was not original, and partial gastrectomy had OesoPhageal surgery 177 been advocated by Wangensteen and Leven in I9498. I carried out gastric resection, vagotomy and pyloroplasty, and pyloroplasty alone (Table II). Experience showed that this indirect approach was often unsuccessful and that any further operation could be made difficult by what had been done before. TABLE II r95' and results of Procedures carried out between I96I in an attempt to improve the surgical treatment Adults: males 70, females 131. Children under 5: males 8, females 3. No of patients operated on: 150 Conservative treatment 62. Simple repair (with vagotomy and/or pyloroplasty 2I) (with partial gastrectomy or gastroenterostomy I 2) Pyloroplasty and/or vagotomy alone... I 0 Partial gastrectomy alone i6 Total gastrectomy I I Partial oesophagectomy and high oesophagogastric anastomosis Ig (with pyloroplasty... 8) Oesophagocardioplasty combined with pyloroplasty or gastroenterostomy I 6 Cardiac sphincter and reflux oesophagitis The disappointments following operation led to renewed interest in the cardiac sphincter. Early research had been concentrated on anatomy. With the development of improved apparatus and new techniques it became possible to measure intraluminal pressures accurately, to measure the ph of the oesophageal contents, and to study motility by cineradiography. All these factors contributed to a fresh approach to the problem, and this time interest was directed towards physiology and function rather than to anatomy. Code9, Inglefingerl0, and others showed by pressure studies that the old idea of an intrinsic sphincter in the wall of the oeso- 78

4 178 R H Franklin phagus itself is correct. This sphincter is influenced not only by factors such as gastric acidity but also by gastric hormones. As a working hypothesis the cardiac sphincter, or more properly 'valve', may be regarded as consisting of two components, an intrinsic part formed by the lower part of the circular muscle of the oesophagus and an extrinsic part which depends for its effect on the anatomical arrangements in the region of the cardia which have been mentioned. The mechanism may be 'unlatched' by drawing the cardia upwards into the chest, straightening the angle of insertion of the oesophagus into the stomach and so allowing reflux to take place. This separation of the two components of the valve-like mechanism takes place in the normal person during the act of vomiting or belching and is not followed by any ill effects. In the case of the person with a sliding hernia, however, the efficiency of the valve mechanism is diminished or absent the whole time, and in these circumstances reflux will oecur freely and frequently and often for long periods without interruption when the patient is asleep. This hypothesis could explain the absence of symptoms in those individuals who in spite of a weak extrinsic component are able to prevent reflux by the unaided action of a particularly effective intrinsic component. It is significant that reflux oesophagitis is seen most frequently in infancy and late middle age. In the infant the mechanism at the cardia is poorly developed and indeed it is to the infant's advantage that this should be so-if a feed is excessive the surplus is returned promptly and without effort. Most infants are unaffected by this reflux, but a minority develop symptoms of oesophagitis. Whether or not the infant develops oesophagitis may be determined by the frequency and length of time of reflux or it may be that the nature of the reflux is more irritating in some instances. The peak incidence is seen in middle age, when overweight, loss of muscle tone, and general flabbiness make themselves evident. Other cases are seen during pregnancy, after severe illnesses with prolonged recumbency, or when a nasogastric tube has been in position for a long time. It is not uncommon for symptoms to arise following the use of an abdominal or spinal support. When oesophagitis persists there may be progressive shortening of the oesophagus and fibrosis may be added. In some instances the primary disorder may be excessive contraction of the longitudinal muscle. The part played by the longitudinal muscle has been studied by Daintree Johnson". Belsey recognized that hernial repair as originally carried out did not always prevent reflux, and he evolved a modified procedure"2. The aim of this operation is to produce firm union between the fundus of the stomach and two-thirds of the circumference of the front of the oesophagus. The lower oesophagus is restored to its abdominal position, where it is capable of being compressed against the repaired hiatus. This type of operation cannot be carried out if much shortening of the oesophagus has occurred. In such cases one method of overcoming the difficulty has been to interpose an isolated segment of small intestine or colon. This involves a series of anastomoses. In order to deal with the problem of the short oesophagus more simply and more safely Collis3 devised the operation of gastroplasty. The cone of stomach which has been drawn up through the hiatus by the shortening of the oesophagus is remodelled into a tube by a suitable incision and resuture. A repair of the hernia can then be carried out around this gastric tube. Yet another method of controlling reflux is by the operation of fundoplication intro-

5 duced by Nissen in Nissen's fundoplication consists of a complete wrap-round procedure in which the fundus is mobilized and brought around the back of the cardia and sutured so as to form a complete cuff of stomach. It is not dependent upon repair of the hernia and it controls reflux even if it is not possible to replace the stomach below the diaphragm (Fig. i). I have used Nissen's fundoplication in the past few years with the addition of pyloroplasty; where possible I have repaired the hernia as well, and should an ulcer be present I have included truncal vagotomy15. Stricture: illustrative cases I will discuss some illustrative cases and describe what I did then and what, in the light of subsequent knowledge, I would do now. In 1946 a woman of 33 came under my care suffering from dysphagia. The date is important; Allison's work had yet to be published and we were still in the confused era and operations on Oesophageal surgery 179 the oesophagus were extremely hazardous. Her story was dramatic. When she was in her 8th month of pregnancy, having been perfectly well until then, she suddenly had an eclamptic fit and became unconscious; 5 d later Caesarean section was performed and she was delivered of a stillborn child. She is said to have remained unconscious for a further i o d. A month later she complained of retrosternal pain and dysphagia. The dysphagia increased and within another 3 weeks she was having great difficulty even with liquids. She weighed 40 kg (6 stone 3 lb), having lost over I 9 kg (3 stone). Gastrostomy was carried out and she started to gain weight. The barium swallow at this time showed a high stricture. This was confirmed by oesophagoscopy, and ulceration was seen at 25 cm. Biopsy showed granulation tissue infiltrated with polymorphs and with no sign of malignancy. The patient continued to improve with gastrostomy feeds, and cautious autobouginage was started; a week later she was able to swallow liquids and a little solid. Slight bleeding occurred, however, and the bouginage was discontinued. Oesophagoscopy 3 weeks later showed the condition to be unchanged. It was decided with some rcluctance that exploration was necessary. It must be remembered *d I b FIG. I Modified Nissen's fundoplication: (a) Stage I; (b) Stage IL

6 i8o R H Franklin that ocsophageal resections at that time were very dangerous and that the patient was a young woman of 33 with what appeared to be a benign condition. Transthoracic exploration from the right side showed that the upper oesophagus was dilated, and at the level of the root of the lung the oesophagus was thickened for a distance of 4 cm ( X in). When the oesophagus was opened above the affected arca the mucosa appeared normal and the lumen at the site of the stricture would just admit a fine probe. Oesophagoplasty was carried out. The patient had a stormy convalescence but on discharge was eating solid food without difficulty. She was sent home with instructions to continuc autobouginage. Six months later she returned with recurrent dlysphagia, and gastrostomy was again carried out. This was followed by retrograde dilatation, and soon she was able to resume autodilatation. After another 3 months she relapsed again and it was decided that resection could no longer be avoided. Resection with oesophagogastric anastomosis was performed and she made a good recovery and was discharged eating normally. Histological examination showed that the epithelium was thinned but intact. There was thickening and dense fibrosis of the submucosa, destruction of the muscularis mucosae, and fibrosis of the connective tissue between the muscle bundles. The overall picture was considered to be one of regional ocsophagitis. The patient was reported as an cxample of this condition. Shc was followed up regularly during the years that followed and had no dysphagia at first. During these years reflux oesophagitis had become a wellrecognized entity and resections were being carried out more and more to relieve those patients who had developed a stricture. There was much discussion as to the best way of restoring continuity. I favoured oesophagogastric anastomosis because of its relative simplicity, but many surgeons avoided this method for fear of setting the stage for yet another stricture. Instead they preferred to use a segment of colon or small bowel in spite of the number of anastomoses required. When my patient reported 9 years later with recurrent dysphagia these fears seemed to be well founded. I was therefore pleased to find on investigation that her obstruction was not in the oesophagus but at the pylorus. Following a pyloroplasty her socalled dysphagia disappeared. She has been followed up regularly since and now, 25 years after her resection, she is swallowing normally. In retrospect it seems clear that this patient was a straightforward example of reflux oesophagitis brought about by her severe illness accompanied by coma. How should we manage such a case today? First of all we have learnt that dilatation of the stricture or a plastic operation to enlarge the lumen will inevitably lead to further stricture formation unless steps are taken at the same time to prevent reflux. We know too that in some cases a stricture which appears at first to be completely irreversible is capable of resolution if reflux can be prevented. If this particular patient presented now I would see if it was possible to pass a No i6f bougie under anaesthesia. If such proved to be the case I would carry out repair of the hernia, Nissen's fundoplication, and pyloroplasty. If it proved impossible to pass the bougie, and having in mind the high level of the strictture, I would proceed to resection and gastro-oesophageal anastomosis with the addition of a pyloroplasty. Further experience has led me to believe that if resection is necessary in cases of stricture it is satisfactory to use the stomach to restore continuity provided that the anastomosis is made high enough and provided that a pyloroplasty is carried out at the same time. A girl of 14 came under my tare in I951 complaining of dysphagia which had been increasing for i months. Barium swallow showed a stricture of the oesophagus above a hiatus hernia and she was treated by autobouginage together with olive oil and antacids. She made rapid progress and was sent home to continue with her treatment. She failed to attend the follow-up clinic and was not seen again until just over a year later. She was then admitted as an emergency with complete dysphagia. She weighed 25 kg (3 stone I 3 lb). Her skin was dry and she had a rash thought to be due to vitamin deficiency. An emergency gastrostomy was carried out and this was followed 2 months later by resection and oesophago-gastric anastomosia (Fig. 2). Now, over 20 years later, she is married and has 2 children.

7 Oesophageal surgery i 8I * ~ under these circumstances, it was not possible to get an instrument past the stricture. Although the oesophageal epithelium appeared normal at the te of obstruction, there was still the possibility T. of a carcinoma lying at a lower level and infiltrating upwards in the submucosa. Exploration and resection were therefore carried out, continuity being restored by oesophagogastric anastomosis. Subsequent histological examination showed a benign stricture with extension of the gastric Te l omucosa up to the lower end of the stricture. (a) (b) FIG. 2 (a) Qesophageal stricture with gross wasting (b) Three months after resection and oesophagogastric anastomosis.a This was, I believe, an example of Barrett's gastric-lined oesophagus-a congenital condition from which no harm resulted until ~~~ ~~~ ~she developed a hiatus hernia with reflux in On 948. Then the part of the oesophagus to be damaged was that lined by normal epithelium and it was at the lower limit of this hat the, stricture formed. I think that exgr-pa patient may develop a high Banum. benign stricture quite suddenly in middle The lesson to be learnt here is the danger of attempting to treat such a case by dilatation alone. If in addition an operation to prevent reflux had been carried out I do not think that resection would have been needed. On the credit side of the account is the satisfactory behaviour of the stomach which was used to restore continuity. The next patient, a woman of 46, presented in In I948 she had started to have abdominal pain followed shortly by dysphagia, which was at first subjective and intermittent. The symptoms gradually became worse and when she was admitted to hospital in I952 she was very pale and wasted and had had a recent weight loss Of 20 kg (3 stone). Barium swallow showed a high stricture (Fig. 3). Oesophagoscopy was carried out to determine the nature of the stricture. The examination was FIG- 3 Benign stricture givi'ng radiological not satisfactory because, as sometimes happens appearance of carcinoma.

8 182 R H Franklin FIG. 4 Oesophageal stricture which proved to be malignant in spite of its benign appearance. The short history and the difficulties in obtaining a biopsy may lead to a diagnosis of malignancy in these patients. There is a possibility too of a mistaken diagnosis in the other direction. For example, in a woman of 76 the X-ray was reported confidently as showing a benign stricture above a hiatus hernia (Fig. 4). On exploration the stricture proved to be malignant. of the patient may make oeso- The build phagoscopic examination difficult or dangerous. Such was the case with a physician of 64 who came under my care (Fig. 5). He had a long history of duodenal ulcer, including haematemesis and melaena. For the past few months he had suffered from intermittent dysphagia which at times was complete. At operation he was found to have a very wide oesophageal hiatus with a sliding hemia and a grossly deformed duodenum. The lower part of the oesophagus was palpated very easily, the stricture was considered to be benign, and it was possible to introduce a No I6F bougie. The procedures carried out were truncal vagotomy, repair of the oesophageal hiatus, fundoplication, and gastroenterostomy. The operation was followed by complete symptomatic relief. A few years ago I would have subjected this patient to resection. It has been mentioned that the mechanism at the cardia is poorly developed in the infant and that in a few cases this may lead to the development of reflux oesophagitis. An unusual example of this is reported below. FIG. 5 Spinal deformity making endoscopy difficult or dangerous..

9 Oesophageal surgery I83 Two identical twin girls aged 12 came under my care in I967. In each case Rammstedt's operation had been performed owing to troublesome 'vomiting' in infancy. Improvement did not take place, however, and each had been restricted ever since to a semisolid diet; when I first saw them neither had ever had a proper solid meal. In each case the barium swallow showed a stricture above a hernia. Both were treated by repair of the hernia, fundoplication, and pyloroplasty with complete symptomatic relief (Fig. 6). Although many strictures due to reflux can be improved in this way, some may require resection or other procedures. Such, was the case with a girl of i 9 who ~ ~ suffered acute renal failure following severe pelvic infection in i1965. She was treated by peritoneal dialysis, during the course of which she had a pulmonary embolism followed by cardiac arrest. She was fed through a nasogastric tube for one month and was put on anticoagulants. When I saw her she had almost complete dysphagia and the barium swallow showed a stricture (Fig. 7). I was unable to pass the smallest bougie. Gastrostomy was carried out. When her condition had improved she was treated by resection and high gastro-oesophageal anastomosis. Normal swallowing was restored and in years later-she sent me her photograph after winning a beauty queen competition (Fig. 8). FIG. 6 Identical twins treated by repair of The ability to limit reflux by means of hernia, fundoplication, and pyloroplasty. FIG. Stricture treated by resection and oesophagogastric anastomosis.

10 I84 R H Franklin FIG. 8 Five years after resection and oesophagogastric anastomosis. fundoplication opens up new possibilities in the treatment of benign strictures. A short stricture may be successfully corrected by dilatation or by a plastic procedure provided that this is combined with fundoplication and pyloroplasty. Management in the absence of stricture I have devoted some time to a consideration of strictures because not only do they produce serious symptoms but they are by no means uncommon. In a personal series of 354 operations for hiatus hernia there were no fewer than I 28 patients in whom the operation was undertaken because of a stricture. How should we manage the patient who does not have a stricture? Infants, I believe, should be treated conservatively in the first instance. With rigorous postural treatment many will become normal. It is, however, very important to keep a careful watch because a stricture may develop quickly. Operation should be undertaken at the first sign of narrowing. If the patient is an adult with a sliding hernia and pain is the only complaint it is essential to make sure that this pain is due to reflux. A careful history, X-ray, and oesophagoscopic examination will usually serve to establish this and exclude such alternative diagnoses as biliary or cardiac disease or associated conditions such as peptic ulceration. In some cases perfusion tests or manometric studies may be useful, but more often these are valuable tools of research rather than essential for dictating treatment. The diagnosis having been established, a determined attempt should be made to control the condition medically before subjecting the patient to an operation. He should be advised to follow a strict conservative regimen for about 6 weeks. Particular emphasis should be placed on weight reduction and the removal so far as possible of all factors which favour reflux. This will entail attention to posture at all times and the discarding of tight abdominal supports. In addition, antacids must be given freely. Failure to obtain relief under such a regimen calls for an operation. The operation that I would carry out for such a patient consists of repair of the hernia, fundoplication, and pyloroplasty. Should a gastric or duodenal ulcer be present I would add vagotomy. A large hiatal hernia (Fig. 9) even without symptoms of reflux is an indication for surgical repair. The risks of intermittent obstruction, bleeding, and fatal strangulation are always present. Repair by means of a transthoracic approach is usually straightforward. A third indication for operation is bleeding. If the bleeding is due to oesophagitis it

11 Oesophageal surgery 185 investigation are now available, and if these are made use of to the full we may look forward to the time when some of the drastic procedures which I have described will no longer be necessary FIG. 9 Large 'para-oesophageal hernia'. is usually occult and an operation to prevent reflux will suffice. If frank haematemesis or melaena has occurred it is likely that a gastric or duodenal ulcer is present and it will be necessary to add vagotomy or resection. Recent observations suggest that reflux may cause cricopharyngeal spasm which in turn may lead to the formation of a pharyngeal pouch. This may be yet another indication for preventing reflux. Conclusion In conclusion I would like to urge the need for continued research into the mode of action of the oesophagus. Many methods of References Hill, J D (I870) Transactions of the Pathological Society of London, 21, Hume, H G (1843) British Medical Journal, 2, Vinson, P P (1923) American Journal of Obstetrics and Gynecology, 6, Kelly, A B (I930) Proceedings of the Royal Society of Medicine, 23, Allison, P R (I948) Thorax, 3, Barrett, N R, and Franklin, R H (I949) British Journal of Surgery, 38, Barrett, N R (1950) British Journal of Surgery, 38, I Wangensteen, 0 H, and Leven, N L (I 949) Physiological Reviews, 38, Code, C F, et al. (I962) Gastroenterology, 43, 521. I0 Inglefinger, F J (1958) Physiological Reviews, 38, 533. ii Johnson, H D (I966) Gut, 7, Baue, A E, and Belsey, R H R (I967) Surgery, 62, Collis, J L (I970) Annals of the Royal College of Surgeons of England, 46, Nissen, R, and Rosetti, M (I962) Physiological Reviews, 38, 583. I5 Franklin, R H, Iweze, F I, and Owen-Smith, M S (I973) British Journal of Surgery, 6o, 65.