Conservative Operations for Peptic. Esophagitis with Stenosis in Columnar-Lined Lower Esophagus

Transcription

1 Conservative Operations for Peptic.. Esophagitis with Stenosis in Columnar-Lined Lower Esophagus A. P. Naef, M.D., and M. Savary, M.D. ABSTRACT Columnar epithelial lining of the lower esophagus (Barrett s esophagus) was found in 62 patients during 4,950 esophagoscopies done from 1963 to The important esophagoscopic findings, based on esophagography and histological examination, are described. Reflux was always present; hiatus hernia was demonstrated in 59 of the 62 patients and peptic stenosis in 27. Adenocarcinoma was diagnosed in 9 patients and Barrett s ulcer in only 4. Surgical treatment is essentially founded on the Nissen fundoplication. This procedure eliminates peptic reflux with certainty and thus cures the patient of ulcerative esophagitis. The postoperative disappearance of peptic stenosis, often without instrumental dilation, has been regularly observed. C olumnar epithelial lining of the distal esophagus, described by Barrett [31, Allison and Johnstone [21, and others [12, 231, is undoubtedly a frequently overlooked anomaly [41 (Fig. 1). It resembles stomach on the inside and esophagus on the outside, in Barrett s words [41, and is frequently, if not always, associated with a hiatus hernia [l, 9, 24, 261. The condition, commonly called Barrett s esophagus, probably results from the metaplastic extension orally of columnar epithelium from the gastroesophageal junction which occurs during the healing process of peptic esophagitis [Z, 4, 7, 8, 151. Ulcerative peptic esophagitis, fibrotic strictures, and carcinoma are frequent complications [l, 9,24, 261. The purposes of this paper are to establish the clinical, endoscopic, and pathological characteristics of so-called Barrett s esophagus; to demonstrate its relation to hiatus hernia and especially to peptic esophagitis from gastroesophageal reflux; and, finally, to show that a simple antireflux operation (the Nissen fundoplication) allows cure of peptic esophagitis and strictures at the mucosal junction of Barrett s esophagus as well as of peptic lesions situated on residual squamous islands at any level of the columnar-lined esophagus [ 191. From the Departments of Surgery and Ear, Nose, and Throat, Yverdon Hospital; the Department of Thoracic Surgery, University of Geneva; and the Ear, Nose, and Throat Department, University of Lausanne, Switzerland. Presented at the Eighteenth Annual Meeting of the Southern Thoracic Surgical Association, Tampa, Fla., Nov. 4-6, Address reprint requests to Dr. Naef, Yverdon Hospital, 1400 Yverdon, Switzerland. VOL. 13, NO. 6, JUNE,

2 NAEF AND SAVARY 0 SQUAMOUS ERTHELIUM A COLUMNAR ERTHEUW - FIG. 1. (C. D., 65 years.) Typical instance of columnar lining of lower esophagus complicated by carcinoma at the distal end of the columnar heterotopia. (A) Endoscopic findings. (B) Esophagogram. (HH = hiatus hernia.) Materials and Methods At the Yverdon and Lausanne Hospitals from 1963 to 1971,4,950 esophagoscopies were performed-many of them done systematically prior to Nissen fundoplication operations for hiatus hernia-that revealed the surprising number of 62 patients with columnar-lined lower esophagus. Esophagographic and microscopical documentation was obtained for every patient, and typical examples are presented. Esophagoscopy in the 62 patients with Barrett's esophagus demonstrated gastroesophageal reflux in all patients as well as hiatus hernia in 59, with a short esophagus in almost half of these; peptic esophagitis in 57; erosions in 30; fibrotic strictures in 27; adenocarcinoma in 9; and a typical Barrett's ulcer in 4 of the 62 patients. Esophagography has been essential in obtaining a precisely documented preoperative and postoperative study, which is impossible to achieve by comparative roentgenography alone. Esophagography furthermore allows establishment of the precise geography of the squamocolumnar junction and B 544 THE ANNALS OF THORACIC SURGERY

3 Peptic Esophagitis with Stenosis 0 EPlDERMOlD MKOSA COLUMNAR MUCOSA FIG. 2. Endoscopic aspect of columnar-lined lower esophagus. TYPE I TYPE I1 the scattered islands and rings of squamous epithelium interrupting the columnar epithelium [24, 251. The exact topography of the squamocolumnar distribution remains constant, even after complete healing of the peptic ulceration (see Figs. 3, 4), as soon as the process of peptic esophagitis has been arrested by a Nissen fundoplication [261. We distinguish two definitely distinct types of squamocolumnar junction [26] (Fig. 2). In Type I, the junction is linear and the columnar epithelium begins in a circular fashion at or about the aortic arch (Figs. 3, 4). In Type I1 the mucosal junction is irregular, often interrupted by scattered, persisting islands of squamous epithelium. The demarcation is generally 3 4 FIG. 3. (P. N., 12 years.) Photograph of the squamocolumnar junction, Type I. On the left is the most proximal view of the line of demarcation, and on the right, the most distal view (3 cm. lower). FIG. 4. (Same patient as in Fig. 3.) The uniformly columnar heterotopia below, interrupted on the two right-hand views by a stenosis located on a residual squamous ring. VOL. 13, NO. 6, JUNE,

4 NAEF AND SAVARY FIG. 5. (P. P., 50 years.) Type ZI squamocolumnar junction, showing irregular demarcation line one year after operation. somewhat lower than the aortic arch and may be observed at any level of the lower esophagus (Figs. 5, 6). Our material seems to show that the anomaly is discovered with greatest frequency during childhood up to age 15 (Type I) and in the older patient from 55 years upward (Type 11) (Fig. 7). We have practically never discovered a case in the intermediate-age group from 15 to 45 years. Type I has been discovered essentially during childhood and may well be congenital, while Type I1 typically occurs in adults and in our opinion is an acquired heterotopia. Microscopical examination of biopsy material from different levels all the way down reveals that peptic esophagitis and strictures are never located on columnar epithelium, but always on the squamous side of the mucosal junction or on scattered squamous islands or rings located distally [17, 24, 261. This absolute rule was confirmed by esophagography and microscopical examination of biopsy material in all 62 patients. The heterotopic columnar epithelium is formed by typical mucus-secreting cells but does not contain any acid-secreting parietal cells [2, 14, 15, 23, 301. Surgical Treatment Although we naturally agree that surgical treatment depends upon the severity of the stricture and should be individualized, we believe that basically the number one goal should be the elimination of gastroesophageal reflux. Historically, surgeons and endoscopists have usually directed treatment at the localized stenotic lesion, whether employing simple dilation, partial esophagectomy with or without jejunal [13, 281 or colonic [5] interposition, plastic procedures of the Thal type [291, or, more recently, acid- A B FIG. 6. (Same patient as in Fig. 5.) (A) A more distal view two weeks after Nissen operation showing scattered squamous islands interrupting the columnar heterotopia. (B) Same view one year later. The geography of demarcation and squamous islands has subsequently remained stable for several years. 546 THE ANNALS OF THORACIC SURGERY

5 Peptic Esophagitis with Stenosis '5 + $lo-- LL 0 TYPE I1 FIG. 7. Age distribution of 62 fiatients with columnar-lined lower o lo WAGE esophagus. (yr.) diminishing and drainage operations such as gastric resection [311, vagotomy [22], pyloroplasty [21, 221, or antrectomy [6]. Only recently have several publications advocated a principle which we have applied independently to our patients since 1966-eliminating the reflux by any one of the effective methods [lo, 11, 201. In our hands, the Nissen [19] procedure, which has been performed in more than 300 patients with simple or complicated hiatus hernia, has been almost foolproof. In a critical reexamination of 129 patients, one of our assistants discovered only 2 recurrences and no lasting dysphagia due to organic postoperative narrowing at the site of the fundoplication. Stenosis has only been observed in a few patients operated upon elsewhere or by the younger surgeons of the staff [18]. The results of operation for complicated Barrett's esophagus are summarized in the Table. Only the 17 patients operated upon at the Yverdon Hospital were available for follow-up, but they are doubtless characteristic of the overall picture. The only death following Nissen fundoplication was that of a patient whose condition was desperate and whom we accepted for a fourth reoperation. He died from perforation of a duodenal stress ulcer and gastrointestinal hemorrhage. When dealing with associated peptic stenosis, usually in older patients RESULTS OF OPERATION FOR COMPLICATED BARRETT'S ESOPHAGUS No. of Type of Lesion Procedure Patients Erosive Stenosis Result Nissen fundoplication Abdominal excellent Thoracic excellent, Resection" death 1 excellent, Total 17 1 death 15 excellent, 2 deaths none patient had Banett's esophagus and cancer. VOL. 13, NO. 6, JUNE,

6 NAEF AND SAVARY o s a w s EPlTHtLluM COLUMNAR ERTHELIW FIG. 8. (C. L., 59 years.) Drawing of the endoscopic findings and esophagograms, showing peptic esophagitis of the suprastenotic squamous mucosa and stenosis at the union of the middle and lower esophagus. Below the stenosis is a 5 cm. long segment of columnarlined esophagus with squamous islands continuing into the sliding hiatus hernia. (HH = hiatus hernia.) of the bad-risk type, we have chosen to ignore the peptic stricture and to eliminate the acid reflux by a simple Nissen fundoplication. All the strictures disappeared after a few weeks, usually without the help of instrumental dilation (Fig. 8). We admit that there might be a case for resectional operation in the truly exceptional patient having a tight stricture with panmural esophagitis [ZO]. Even in this situation, however, the elimination of reflux produces astonishing results, as happened in 1 of our patients (Figs. 9, 10). With Hill and his associates [lo], we believe that even in the presence of the frequently associated slightly shortened esophagus, the anatomical gastroesophageal junction usually can be pulled down below the diaphragm sufficiently for an abdominal antireflux operation to be performed. Marked shortening of the esophagus associated with Barrett s esophagus does exist, however, and preoperative endoscopy as opposed to roentgenography allows the unfavorable hernias that cannot be reduced to be distinguished from the usual, curable ones. When endoscopy shows that the cardia cannot be replaced into the abdominal cavity, it is probably a mistake to undertake laparotomy. In these patients, a deliberately thoracic operation with construction of an intrathoracic fundoplication to be left above the diaphragm is our procedure of choice. It can be combined with forcible endoscopic dilation under surgical control through the open chest. Comment Columnar epithelial lining of the lower esophagus, if systematically looked for in patients with reflux and hiatus hernia, is a relatively frequent 548 THE ANNALS OF THORACIC SURGERY

7 Peptic Esophagitis with Stenosis 0 SOUAMOUS EPITHELIUM \ COLUMNAR EPITHELIUM FIG. 9. (G. S., 62 years.) Drawing of esophagoscopic findings and esophagogram, showing peptic erosions and tight panmural stricture just below the level of the aortic arch. Columnar heterotopia of the lower esophagus is seen, continuing into a sliding hiatus hernia. FIG. 10. (Same patient as in Fig. 9.1 Photographs of the esophagus taken at interuals after a Nissen fundoplication. (A, B) Ulcerative and stenotic esophagitis with infiltration and fixation of the esophageal wall. (C, D) Same view one month after operation. There is persistence of fairly marked esophagitis and stricture. (E, F) Same view six months after operation. There is complete disappearance of esophagitis and definite widening of the stenotic ring. E F VOL. 13, NO. 6, JUNE,

8 NAEF AND SAVARY occurrence. It was found in 62 patients during a series of 4,950 esophagoscopies. Esophagographic and microscopical documentation obtained in the 62 patients permitted the juvenile (Type I) linear squamocolumnar junction at the aortic arch to be distinguished from the adult (Type 11) disease, consisting of irregular mucosal demarcation with scattered squamous islands in the midst of heterotopic columnar metaplasia. Peptic strictures are always located on the squamous side of the demarcation or on squamous residual islands, but never on columnar epithelium. Esophagoscopy is the keystone to a thorough preoperative study and a wellplanned therapeutic approach to the hernia. The Nissen fundoplication is the ideal antireflux operation in all patients with hiatus hernia. It also allows all peptic lesions, including strictures, to heal without associated instrumental dilation. Esophagoscopy shows that a supradiaphragmatic intrathoracic Nissen wraparound procedure even cures peptic esophagitis with stenosis in patients with associated acquired shortening of the esophagus. Major resectional operation in olderage, bad-risk patients seems unwarranted except in the very rare case of a tight stricture with panmural esophagitis. References 1. Adler, R. H. The lower esophagus lined by columnar epithelium: Its association with hiatal hernia, ulcer, stricture and tumor. J. Thorac. Surg. 45: 13, Allison, P. R., and Johnstone, A. S. The esophagus lined with gastric mucous membranes. Thorax 8:87, Barrett, N. R. Chronic peptic ulcer of the oesophagus and oesophagitis. Br. J. Surg. 38:175, Barrett, N. R. The lower esophagus lined by columnar epithelium. Surgery 41:881, Clowes, G. H. A., Jr., Neville, W. E., and Gregorie, H. B. Esophageal Resection and Replacement with a Segment of Colon. In P. E. Cooper (Ed.), The Craft of Surgery. Boston: Little, Brown, Ellis, F. H., Jr., Andersen, H. A., and Clagett, 0. T. Treatment of short esophagus with stricture by esophagogastrectomy and antral excision. Ann. Surg. 148:526, Goldman, M. C., and Beckman, R. C. Barrett syndrome: Case report with discussion about concepts of pathogenesis. Gastroenterology 39: 104, Hayward, J. The lower end of the esophagus. Thorax 16:45, Heitmann, P., Strauszer, T., Sapunar, J., and Larrain, A. Lower esophagus lined with columnar epithelium: Morphological and physiological correlation. Gastroenterology 53:611, Hill, L. D., Gelfand, M., and Bauermeister, D. Simplified management of reflux esophagitis with stricture. Ann. Szirg. 172:638, Johnston, J. H., Jr. Gastric lined esophagus associated with rings and stenoses. Ann. Surg. 173:641, Lortat-Jacob, J. 0. L endobrachy-oesophage. Ann. Chir. 11: 1247, Merendino, K. A., and Dillard, D. H. Concept of sphincter substitution by interposed jejunal segment for anatomic and physiologic abnormalities at esophagogastric junction. Ann. Surg. 142:486, THE ANNALS OF THORACIC SURGERY

9 Peptic Esophagitis with Stenosis Monti, M., Fasel, J., and Savary, M. Le problkme histologique des hdttrotopies epitheliales etendues du bas-oesophage. Ann. Otolaryngol. Chir. Cervicofac. 86:380, Mossberg, S. M. The columnar-lined esophagus (Barrett syndrome): An acquired condition? Gastroenterology 50:671, Naef, A. P. La chirurgie du reflux gastro-oesophagien grave sans hernie hiatale manifeste. Praxis 19:486, Naef, A. P., and Savary, M. Endoscopie et chirurgie de l'endobrachyoesophage sans stdnose ni ulchre. Presented at LXXe Congrb Fransais de Chirurgie, Naef, A. P., Savary, M., and Jaques, W.-A. Evaluation oesophagoscopique et clinique de la fundoplication selon Nissen. Helv. Chir. Acta 37:107, Nissen, R., and Pfeiffer, K. Zwerchfellhernien: Klinische Zndikation, Chirurgie, Technik. Bern and Stuttgart: Hans Huber, Paulson, D. A. Benign stricture of the esophagus secondary to gastroesophageal reflux. Ann. Surg. 165:765, Payne, W. S. Surgical treatment of reflux esophagitis and stricture associated with permanent incompetence of the cardia. Mayo Clin. Proc. 48:553, Payne, W. S., Andersen, H. A., and Ellis, F. H. The treatment of short esophagus with esophagitis by gastric drainage procedures with and without vagotomy. Surg. Gynecol. Obstet. 116:523, Pierce, J. W., and Creamer, B. The diagnosis of the columnar lined esophagus. Clin. Radiol. 14:64, Savary, M. La jonction muqueuse gastro-oesophagienne: Aspect endoscopique normal et pathologique. Ann. Otolaryngol. Chir. Cervicofac. 86: 373, Savary, M. L'apport de la photographie en endoscopie oesophagienne basse. Ann. Otolayyngol. Chir. Cervicofac. 87:684, Savary, M. L'endobrachy-oesophage (esophagus lined with columnar epithelium): A propos de 43 observations endoscopiques. Ther. Umsch. 28: 148, Skinner, D. B., and Belsey, R. H. Surgical management of esophageal reflux and hiatus hernia. J. Thorac. Cardiovasc. Surg. 53:33, Skinner, H. H., and Merendino, K. A. An experimental evaluation of an interposed jejunal segment between the esophagus and the stomach combined with upper gastrectomy in the prevention of esophagitis and jejunitis. Ann. Surg. 141:201, Thal, A. P., Hatafuku, T., and Kurtzmann, R. New operation for distal esophageal stricture. Arch. Surg. 90:464, Trier, J. S. Morphology of the epithelium of the distal esophagus in patients with midesophageal peptic strictures. Gastroenterology 58:444, Wangensteen, 0. H., and Leven, N. L. Gastric resection for esophagitis and stricture of acid-peptic origin. Surg. Gynecol. Obstet. 88:560, VOL. 13, NO. 6, JUNE,