Experience with the Thal Gas troesophagoplasty

Transcription

1 Experience with the Thal Gas troesophagoplasty Wesley S. Wise, M.D., Carlos H. Rivarola, M.D., G. Doyne Williams, M.D., William J. Fink, M.D., and Raymond C. Read, M.D. T he idea that the wall of a normal segment of small bowel can be made to perform double duty by using it to cover a defect in another portion of the gastrointestinal tract or even in the genitourinary system was introduced by Thal and his co-workers [8] in Employing the same principle, the fundus of the stomach may be brought up through the diaphragm as a patch graft for spontaneous rupture of the esophagus. This concept was expanded to treat esophageal strictures by longitudinal incision, using the fundic patch to cover and enlarge the lumen [6]. Because of reflux, Clarke, Rayl, and Woodward added a Nissen plication to improve the valvelike mechanism [l]. In the present study we report our experience with this new operation and comment on the postoperative competency of the cardioesophageal sphincter mechanism. CASE MATERIAL Sixteen operations were performed by seven different surgeons on 15 patients (14 men, 1 woman). The patients ranged in age from 38 to 69 years, the average age being 59 (Table). The indications for operation were hiatal herniation with peptic stricture in 9 patients, stricture following excision of duplication cyst in 1 patient, stricture following operation for achalasia in 2, and spontaneous or iatrogenic perforation of the lower esophagus in 3 patients. The patient with a duplication cyst also had a hiatal hernia. Of the 10 patients with hiatal herniation, 6 had undergone operations previously for repair of their hernias. A supplemental acid-reducing procedure had been employed in 5 of these patients (vagotomy and pyloroplasty in 4, vagotomy and antrectomy in the other). Of these From the Departments of Surgery, Veterans Administration Hospitals, Little Rock and Fayetteville, Ark., and the University Medical Center, Little Rock, Ark. Presented at the Sixth Annual Meeting of The Society of Thoracic Surgeons, Atlanta, Ga., Jan , We thank James H. Growdon, M.D., Clinical Professor of Surgery, University of Arkansas Medical School, for allowing us to use his case, and Gilbert S. Campbell, M.D., Chairman of the Department of Surgery, for his advice. Address reprint requests to Dr. Read, Veterans Administration Hospital, 300 E. Roosevelt Rd., Little Rock, Ark

2 WISE ET AL. RESULTS OF THAL GASTROESOPHAGOPLASTY IN 15 PATIENTS Patient Operation No. Age&Sex Date Reflux Narrowing Weight Result HIATAL HERNIA & STRICTURE 1 68, M 4/4/68 11 /11/69 (Nissen) 2 45, M 10/21/ ,M 1/7/69 3/26/ ,M , M 5/12/ ,M 7/2/ ,M 7/9/ , M 8/15/ , M 9/3/69 DUPLICATION CYST & STRICTURE 10 38, M 5/2/69 12! 18/69 (N i ssen) ACHALASIA & STRICTURE 11 52, F 1/6/ ,M 2/29/69 PERFORATION 13 47,M 5/26/ , M 12/ , M 6/28/69 Reopera tion - Fair Good - Poor Good Good Good 0 Good - Good - Good - Fair Good Fair Fair Died 0 Poor Good 10 patients, 4 were schizophrenic and under custodial care, 2 were alcoholics, and 1 was mentally retarded. These patients were operated on because of dysphagia, weight loss, and in 1, frequent impaction of ingested foreign bodies. Most had had these complaints for many years despite bougienage. Eight patients could tolerate only a liquid or puree diet. Of the 10 patients, half were inmates of the Fort Roots Veterans Administration Neuropsychiatric Hospital, North Little Rock, Arkansas. One of the 2 patients with achalasia had had two abdominal procedures performed in the early 1950's. The specific operations are unknown, but gastrointestinal series demonstrated a gastroenterostomy. This patient also underwent a Heller myotomy in The other patient, a woman, had undergone resection of the distal esophagus in 1947 for either achalasia or stricture. In both these patients examination revealed a sigmoid-shaped megaesophagus and distal narrowing. In 1 other patient esophagitis was present, and bleeding had occurred twice. Of the 3 patients operated on for perforation, the first was seen 36 hours after onset. Another patient was seen 17 hours after onset. In the third patient the lower esophagus had been torn while he was undergoing a transabdominal vagotomy. This patient had mediastinitis accompanying hiatal hernia and peptic esophagitis, associated with a giant duodenal ulcer and choledochoduodenal fistula. 214 THE ANNALS OF THORACIC SURGERY

3 Thal Gastroesophagoplasty OPERATIONS AND RESULTS The operation as outlined by Thal [61 consists of exposure through the left thorax, incision of the stricture, roofing with a well-mobilized fundic pouch brought through the enlarged esophageal hiatus, and formation of a valve by applying the fundus to the anterolateral two-thirds of the esophagus for a distance of 5 cm. This procedure was used in the first 15 operations. Split-thickness skin grafts, as recommended by Thal, were used in 2 patients whose mucous membranes in the distal one-third of the esophagus were completely replaced by scar tissue. In the last operation, a Nissen plication as proposed by Clarke, Rayl, and Woodward [l] was added, making a collar around the lower esophagus. In 2 patients a similar plication was performed during a second operation because of continuing reflux. The longest stricture treated was 11 cm.; it reached almost to the arch of the aorta. A complementary vagotomy and Heineke-Mikulicz pyloroplasty was added in 4 patients, since they had not had this procedure previously. The patients have been followed for from 4 to 21 months postoperatively (average, 9.6 months). HIATAL HERNIATION WITH PEPTIC STRICTURE Eight of the 9 patients with hiatal herniation and peptic stricture had a gratifying immediate postoperative result and were able to return to a regular diet without dysphagia. The other patient was reoperated upon after two and one-half months because he still was experiencing difficulty in swallowing. Barium studies demonstrated a narrow segment at the apex of the patch. At the second operation the fundic patch was extended proximally and broadened. Roentgenograms made after reoperation showed neither reflux nor narrowing. Three of the 8 patients who responded well showed reflux of swallowed barium in the Trendelenburg position. Two of these 3 patients also demonstrated esophageal narrowing. Both responded to dilation. The third patient with postoperative reflux (but without associated stricture) became symptomatic, with dysphagia and moderate weight loss. Twenty months after his original operation he underwent a transthoracic Nissen plication. He presently has a competent cardioesophageal sphincter mechanism without narrowing. Two asymptomatic patients who did not show reflux in their barium studies had some esophageal narrowing. One patient was dilated once and the other several times during the immediate postoperative course. Four patients gained weight postoperatively, 1 maintained his preoperative weight, and 4 lost weight. The weight loss in 4 patients is no doubt explained by the fact that they have other diseases-alcoholism, cancer, and megacolon. DUPLICATION CYST The patient with stricture following excision of a duplication cyst gained weight while on a regular diet after his Thal procedure, but he did have symptoms of esophagitis, especially when supine. An esophagogram showed no obstruction of flow, but marked regurgitation was noted. A Nissen plication was performed seven months after the Thal procedure. Barium studies now demonstrate his valve mechanism to be competent. ACHALASIA The 2 patients with stricture following previous operative treatment for achalasia tolerated a soft diet immediately after operation. One patient gained 1 1 pounds and no longer regurgitates undigested food; however, esophagograms show slow emptying. The other patient failed to gain weight and soon could again tolerate only liquids. Esophagogram and esophagoscopy revealed another VOL. 10, NO. 3, SEPTEMBER,

4 WISE ET AL. stricture. Dilations were begun, and presently the esophagoscope passed with ease. The esophageal dilatation in the upper esophagus is now less, and the patient is gaining weight. PERFORATION OF THE ESOPHAGUS The patient seen 36 hours after spontaneous rupture of the esophagus died in septic shock four hours after operation. The patient operated on 17 hours after spontaneous perforation survived, but he had a temporary esophagocutaneous fistula. In this patient the esophageal hiatus through which the stomach was brought up into the chest was stretched but not incised. Postoperatively, the fundic pouch in this patient did not empty well. It is possible that the venous drainage was pinched and that this compromised the healing process. Presently, however, the patient is on a regular diet and is asymptomatic. The patient with iatrogenic tear of the distal esophagus also developed a stricture postoperatively which is being dilated periodically up through a No. 26F bougie. In retrospect, a skin graft applied to the mucosal surface of the fundic patch might have helped, since his mucous membrane had been destroyed. COMMENT Thal s concept of bringing the fundus of the stomach into the chest to cover the defect produced by spontaneous rupture of the esophagus has been a valuable contribution to the management of a rare but often fatal condition. These patients are frequently old and have chronic disease, and the diagnosis of such an unusual acute condition is difficult to make, thus delaying operative repair [5]. The time lapse before operation allows gastric juice, saliva, and bacteria to cause extensive gangrenous changes in the esophagus and surrounding mediastinal structures. The esophagus frequently requires extensive debridement and is so edematous that primary closure is generally not possible without causing tension or stricture. The living pedicle graft of stomach with its excellent blood supply serves as an ideal patch, analogous to omentopexy for closure of perforated duodenal ulcer. The rapid downhill course of untreated esophageal perforation is well demonstrated by our first case, a mental patient who was not transferred for 36 hours after onset of symptoms. By then he had developed empyema necessitatis, with infection spreading through the muscles of the chest wall. It would not have been possible to suture the esophagus directly, but the fundic patch adequately covered the rupture. Unfortunately, he died of overwhelming sepsis. Our other case of spontaneous perforation emphasizes the importance not only of freeing sufficient fundus by tying enough vasa brevia so that the patch will lie without tension, but also of making the hiatal opening large enough so as not to embarrass circulation. The serosa of the stomach can then be sutured to the crura and the incised diaphragm. Reoperations on 3 of our patients have clearly demonstrated that a solid union rapidly develops, 216 THE ANNALS OF THORACIC SURGERY

5 Thal Gastroesophagoplasty thus preventing further herniation of stomach or other abdominal content. In applying the Thal procedure to the treatment of benign stricture refractory to bougienage, the situation becomes more complicated because of the associated hiatal herniation and cardioesophageal reflux (Fig. 1). Moreover, unlike cases of spontaneous perforation, the normal squamous epithelium is frequently lost, having been replaced by scar tissue throughout the contracted lower esophagus. Widening of the lumen by bringing up and laying on the adjacent fundus is technically much easier and has a lower morbidity and mortality than jejunal or colonic interposition [4]. Thal suggested originally that the fundic patch would act as a flap valve and prevent regurgitation even though the stomach remained above the diaphragm [7]. Further experience has shown, however, that one cannot depend on this. Thus our incidence of postoperative reflux-4 patients from a total of 14 who survived operation-is similar to that of Thal s-4 of 16 patients. Both are less than the incidence reported by Clarke, Rayl, and Woodward of 4 cases of postoperative reflux from a total of 4 patients [l]. An interesting question is why some patients regurgitate and others A B Fig. 1. (A) Preoperative barium swallow in Patient 5 (Table) showing a typical refractory peptic stricture with hiatal hernia in a patient who had previously undergone hiatal herniorrhaphy with uagotomy and pyloroplasty. (B) Follow-up barium swallow three months after Thal procedure. The fundic pouch is filled with air and barium. Proximal dilatation has decreased, and distally there is an adequate lumen. VOL. 10, NO. 3, SEPTEMBER,

6 WISE ET AL do not with Thal s original procedure. The degree of wrapping and the level of diaphragmatic attachment to the pouch may vary slightly, but it is our impression that the most important factor is how far the incision through the stricture extends into the stomach. In these patients, many of whom have been operated on a number of times, it is often difficult to tell at operation where the stomach ends and the esophagus begins. Our patients had long-standing disease that was resistant to dilation, and in addition, the disease had often been neglected because of the patients severe neuropsychiatric disease; as a result, esophagitis had led to ulceration with extension into the mediastinum. The serosal covering identifying the herniated stomach tends to disappear, while contraction of the fibrosed esophagus pulls the gastric pouch into a tube externally simulating the esophagus. Inside, the extension of columnar epithelium in a damaged esophagus can be mistaken for gastric epithelium. Therefore, we now recommend that when opening up the stricture, the surgeon should begin the incision superiorly in the dilated portion. The incision should then be continued down just far enough to open the lumen adequately, thus preserving as far as possible any intrinsic sphincteric fibers that may contribute to competency of the cardioesophageal junction. If bothersome reflux develops despite such precautions, as it did in 2 of our patients, Nissen plication provides dramatic relief. The excellent results with this procedure support the suggestion by Clarke, Rayl, and Woodward [l] that it be made a part of the original operation. Obviously, it is disappointing that narrowing of the distal esoph- FIG. 2. Typical roentgenographic appearance of the narrow, soft stricture which occurred in a number of our patients in the immediate postoperative period. These strictures responded to bougienage. 218 THE ANNALS OF THORACIC SURGERY

7 Thal Gastroesophagoplasty agus occurred postoperatively in about half our patients (Fig. 2). However, nearly all these strictures, which were different from those seen before the procedure, responded well to simple bougienage. It is too much to expect instant epithelialization of the serosal surface along with resolution of a scarred posterior wall. Hatafuku and Thal [Z] have reported that in the dog it takes three to five weeks for granulation tissue and a thin epithelial covering to develop over the serosa of the fundic patch. Our experience, which is similar to Thal s, suggests that in some patients contraction requiring dilation may take place in the interim. It is possible that our incidence of postoperative stricture would have been less had we applied more often than twice a split-thickness skin graft to the serosa of the fundic patch. We have been impressed by how well the patients eat after operation, even though the esophagogram seems unsatisfactory. Cineesophagography is a much better way of evaluating function in this area. It is important to realize that peptic stricture requiring direct surgical relief (i.e., incision or excision) is so rare that our experience was accumulated from five different hospitals. Obviously, the results might have been more consistent if only one group had been involved. The fact that half our patients had mental disease made subjective evaluation of their operations difficult. The mediastinum was scarred in many of our patients, and the necessary mobilization might have resulted in inadvertent cutting of the vagus nerves, thus interfering with gastric emptying after operation. Furthermore, Thal and co-workers [S] have reported that, experimentally, serosal patches do not heal when placed over defects in the stomach unless vagotomy and pyloroplasty have been performed. We hoped to encourage healing by reducing acid production. In one of our patients in whom pyloroplasty was not done immediately it was required ten days later because of gastric atony. Unlike Thal, we now recommend that a vagotomy and drainage procedure be added routinely. In this regard, one of our patients with postoperative reflux had a negative Hollander test, but bile regurgitated freely, causing pain and inflammation. As has been suggested [3], esophagitis in some patients may be biliary rather than peptic. SUMMARY AND CONCLUSIONS Sixteen Thal gastroesophagoplasties were performed by seven different surgeons in 15 patients aged 38 to 69 years. The procedure was indicated by otherwise refractory benign stricture in 12 patients and by perforations of the distal esophagus in 3 patients. One patient with esophageal perforation died from sepsis soon after operation. The other 14 patients have been followed from 4 to 21 months. Nine of the 14 VOL. 10, NO. 3, SEPTEMBER,

8 WISE ET AL. survivors now swallow normally, 4 are improved, and 1 has shown no improvement. Postoperatively, significant cardioesophageal reflux was demonstrated in 4 of the 14 patients. Two patients had Nissen plication and were relieved of this complication. Seven of the 14 patients developed some narrowing of the distal esophagus soon after operation. One patient underwent reoperation, and the fundic patch was extended with a good result. All but 1 of the other 6 patients responded rapidly to bougienage. One patient required pyloroplasty for gastric atony ten days after operation. We recommend that vagotomy and a drainage procedure be added to the initial Thal procedure. We believe that whenever the strictured esophagus is bereft of epithelium, the serosa of the fundic patch should be skin-grafted. We endorse the suggestion made by Clarke, Rayl, and Woodward [l] that reflux may be minimized by wrapping the stomach completely around the esophagus. Patients should undergo esophagoscopy one month after operation so that any healing contracture may be dilated. REFERENCES 1. Clarke, J. M., Rayl, J. E., and Woodward, E. R. Experience with the Thal and Nissen operations in the treatment of reflux esophagitis with stricture: A preliminary report. Amer. Surg. 35:89, Hatafuku, T., and Thal, A. P. The use of the onlay gastric patch with experimental perforations of the distal esophagus. Surgery 56: 556, Holt, C. J., and Large, A. M. Surgical management of reflux esophagitis. Ann. Surg. 153:555, Merendino, K. A., and Dillard, D. H. The concept of sphincter substitution by an interposed jejunal segment for anatomic and physiologic abnormalities at the esophagogastric junction. Ann. Szirg. 142:486, Paulson, D. L., Shaw, R. R., and Kee, J. L. Recognition and treatment of esophageal perforations. Ann. Surg. 152: 13, Thal, A. P. A unified approach to surgical problems of the esophagogastric junction. Ann. Surg. 168:542, Thal, A. P., Hatafuku, T., and Kurtzman, R. New operation for distal esophageal stricture. Arch. Szirg. (Chicago) 90:464, Thal, A. P., Sukhnandan, R., Arbulu, A., and Hatafuku, T. Patch-grafting of the gastrointestinal and urinary tract. Minn. Med. 49:45, DISCUSSION DR. DONALD L. PAULSON (Dallas, Tex.): I have had the privilege of reading this paper, and I find it a well-written, frank report of an experience with the Thal esophagoplasty. This is a useful procedure for enlarging the lumen of the esophagus at or near the esophagogastric junction. Two requirements must be met, however, to ensure the success of any such procedure. The first of these is the provision of an adequate lumen, and the second is the prevention or correction of gastroesophageal reflux. Failure to correct reflux results in reflux esophagitis with the risk of con- 220 THE ANNALS OF THORACIC SURGERY

9 Thal Gastroesophagoplasty tinued ulceration and stricture formation. Reflux can be prevented or corrected by any one of a number of procedures. These include the Belsey procedure; the Nissen wrap-around procedure, as advocated by Woodward; or the Collis gastroplasty combined with either of these. Common to all these techniques is the application of a fundal patch of stomach to at least two-thirds of the circumference of the esophagus, as emphasized by Thal. The inkwell technique used by Pearson in esophagogastrostomy is based on a similar principle. The authors have used the Thal gastroesophagoplasty in a limited group of patients in whom the indications were clear. Half their patients were also receiving neuropsychiatric care. The surgeon is cautioned, however, against using this procedure overenthusiastically for severe ascending ulcerative esophagitis in which metaplastic changes may have occurred. Resection and colon interposition may be preferable to leaving such an esophageal segment in place, particularly if reflux is not corrected. DR. THOMAS BARTLEY (Gainesville, Fla.): I want to congratulate Dr. Wise and his coauthors for emphasizing the value of fundic patches in esophagoplasty for distal esophageal strictures. This procedure to repair such strictures has probably made ileal and other bowel segment interposition operations obsolete. Dr. Ed Woodward of the University of Florida Hospital has emphasized the need for an associated fundoplication to prevent reflux and early restricture of the patched esophagus. The first 4 patients who had fundic patch operations for esophageal stricture at the University of Florida Hospital all developed significant strictures at the site of the fundic patch late in their postoperative course. Three of these patients underwent subsequent fundoplication, and they are doing fairly well at present, although one requires occasional dilations. The fourth patient did poorly initially and subsequently has been lost to follow-up. Of the next 20 patients who underwent a fundic patch repair of the stricture and an associated fundoplication (Nissen), only 1 patient had significant restricture. This patient did require an ileal interposition operation. Another patient had some trouble swallowing, but this difficulty responded to two or three dilations. DR. W. G. MALETTE (Lexington, Ky.): Our experience with 26 cases leads us to agree with the authors. All these were cases of severe, burned-out stricture, not ulcer. We did do the fundoplications mentioned by Dr. Bartley. In our series, one minor stricture responded to bougienage. We would like to reinforce the essayists plea for the skin graft. DR. RODMAN E. TABER (Detroit, Mich.): I would like to confine my remarks to that group of patients with neglected hernias, which I think furnished half or more of the patients in the series presented by Dr. Heimlich and that presented by Dr. Wise and associates. I think these authors and their co-workers are to be commended for bringing these ingenious procedures to our attention; but possibly we ought to say at least a word for the use of a simple reconstructive procedure in some of these cases. In many situations we see the esophagogastric junction retracted up between the inferior pulmonary vein and the left main stem bronchus. The purpose of the repair, of course, is to get the junction back below the diaphragm and to prevent reflux. It may be necessary to free up the esophagus to above the aortic arch; however, we can always get the stomach down below the diaphragm. The purpose of all these types of surgical repair must be the prevention of reflux. Possibly, simple reconstruction might be tried first and the more extensive procedures reserved for failures. DR. NICHOLAS JOHN DEMOS (Jersey City, N.J.): The authors have given us an VOL. 10, NO. 3, SEPTEMBER,

10 WISE ET AL. excellent method; however, we have successfully used the intercostal pedicle to treat or prevent reflux and to close esophageal perforations. Allison presented the idea of the sling action in the normal gastroesophageal area. The left seventh and the right third intercostal pedicles have been used as slings to control reflux and to prevent esophagitis around an esophagogastrostomy. We use a No. 15 blade to dissect the intercostal pedicle. Terrible hemorrhagic reflux esophagitis has been cured by the pedicle method. The advantages of the pedicle method are (1) it is simple; (2) it can bq used on either side of the chest and at any level; (3) it allows the patient to vomit, which is a very important function. DR. READ: I would like to thank Drs. Paulson, Bartley, Malette, Taber, and Demos for their comments. Dr. Paulson stressed the problem of reflux in all operations in this area. Reflux occurred in about 4 of Dr. Thal s original 14 operations. We had a similar percentage. Dr. Woodward had about 100% reflux, as Dr. Bartley pointed out. Perhaps the difference is related to the amount of stomach that is incised when the incision is made into the stricture. We favor a very conservative approach when going down into the gastric portion of a gastroesophageal stricture. Dr. Malette pointed out the importance of using the skin graft. We agree that perhaps we should have used it more than we did, because we did have a disturbing incidence of postoperative narrowing which we do believe was related to the healing of the surface. Dr. Demos pointed out his pedicle, which, of course, will provide a valve. But unlike the Thal procedure, the pedicle does not act as a replacement for tissue in the esophagus, which is either lost in rupture or lost with stricture. NOTICE FROM THE BOARD OF THORACIC SURGERY The Board of Thoracic Surgery, Inc., announces that after August 1, 1970, its office will be located at East Seven Mile Road, Detroit, Mich THE ANNALS OF THORACIC SURGERY