Problems of achalasia

Abstract

THIS paper is based on an experience of 61 cases of achalasia seen between the years 1936 and 1960.True reflex spasm of the cardia is not under consideration. It is cured by the removal of the exciting cause.In 1876 Zenker studied 17 cases of "simple ecstasy of the oesophagus" and in 1884 von Mickulicz (1904) coined the name " Cardio-spasm".Between the years 1908 and 1912 Plummer (1912) and his colleagues in the Mayo Clinic collected a large series of cases and studied methods of diagnosis and treatment. From this work came the Hummer's bag dilator, later modified by Negus in this country. This bag gave great relief to many sufferers, but, because of the risks involved and the fact that it did not really take into account the pathology involved, was later largely superseded.In I903 G. Manvedel devised a method of approach to the cardiac end of the stomach by making an incision parallel with the left costal margin and dividing costal cartilages with ribs 7, 8, and 9 and hinging up the whole left costal margin. E. Heller in 1914 used this approach in his nowclassical operation of oesophagoplasty. He believed that the cause of the lesion was a true spasm of the circular muscle of the lower 3 cm. of the oesophagus, but he recorded that there was no hypertrophy of muscle in the affected segment. He was the first to see, however, that there was gross and obvious hypertrophy of the oesophageal musculature above the segment. He noted, too, that even under deep anaesthesia the contracted cardiac segment did not relax, and he therefore applied the principle of Rammstedt and divided the longitudinal and circular muscle fibres over the whole affected area. He did this both on the anterior and posterior surfaces in order to ensure an adequate bulge of the mucosa and to effect complete relief. He made no comment in his paper about the obvious contrast between the grossly hypertrophic muscle lesion of the pyloric sphincter and the thin attenuated type of muscle at the lower end of the oesophagus with the hypertrophy confined to the area above it.The principle of Heller's operation is still considered the most effective method of relief to-day, but the operation itself was simplified to its present form in 1942 by Barlow, who used an ordinary paramedian incision and a single anterior division of the musculature.In 1924 Vinson presented a detailed review of 415 patients. He noted that many cases were clearly of long standing before symptoms were sufficiently marked for patients to seek advice. The muscular hypertrophy above the lesion had kept pace, as it were, for long periods with the increasing obstruction. In the long run there was 'esophageal decompensation' often corresponding with the first symptoms of illness.

Oesophageal acid clearing: One factor in the production of reflux oesophagitis

“…This probably accounts in part for the propensity to develop oesophagitis in systemic sclerosis and after treatment for achalasia by myotomy or forceful sphincter dilatation (Barlow, 1961;Ellis and Cole, 1965). However, delayed acid clearing was also found when manometry detected no abnormality of oesophageal peristalsis.…”

The history of British oesophageal surgery.

“…This naturally encouraged the advocates of dilatation and stimulated the introduction ofalternative methods ofstretching the area through the oesophagoscope. 27 The advocates ofmyotomy were slow to counter this trend because it was not easy to find a reason for the unsatisfactory results. Several papers then appeared emphasising the importance of reflux and suggesting surgical steps to prevent it.…”

Reflux after cardiomyotomy

“…Suturing the fundus of the stomach to the diaphragm (Barlow, 1961), pyloroplasty, and gastroenterostomy (Hawthorne, Frobese, and Nemir 1956) have been described. It would appear that these additions to the operation impose an unnecessarily heavy burden on the patient, but they may merit attention where duodenal ulceration and achalasia coexist.…”

“…In the majority the resting pressure was found to be lower than normal but only five had demonstrable reflux. Among 61 patients subjected to cardiomyotomy Barlow (1961) found 15 with some degree of reflux and six with strictures.…”