The anti-reflux mechanism after cardiomyotomy.

Abstract

M (1978). Thorax, 33,[569][570][571][572][573]. The anti-reflux mechanism after cardiomyotomy. Only 18 of 83 patients who had had a cardiomyotomy for achalasia could be induced to reflux barium. Mucosal herniation through the myotomy was shown in most by radiography. Perfusion manometry showed a higher pressure zone in the oesophagogastric junction region in 22 of 24 patients studied. This high pressure zone responded to an increment in abdominal pressure by a greater increment. The same response was seen in a patient with a small hiatal hernia and a myotomy. We conclude that the persisting high pressure zone seen by perfusion manometry is likely to be caused by the hiatus, and that the hiatus rather than the sphincter is likely to be responsible for the incremental response of the high pressure zone to increased abdominal pressure. The anti-reflux mechanism after cardiomyotomy is more likely to be the hiatal mechanism than persisting sphincter fibres.A large proportion of our patients who have had a cardiomyotomy for achalasia do not have symptoms of reflux, and we are unable to show the capacity to reflux barium by radiology. Ellis and Cole (1965) made a similar observation and attributed the persistence of an anti-reflux mechanism to the hiatus. Atkinson (1959) and Ellis et al (1967) recorded a high pressure zone at the oesophagogastric junction in some subjects after cardiomyotomy, concluding that this high pressure zone was caused by persisting sphincter fibres and was the explanation of the lack of evidence of reflux.The technique of myotomy used on our patients makes it unlikely that sphincter fibres persist and our purpose was to investigate the anti-reflux mechanism after such a cardiomyotomy. The hypotheses to be tested were (1) that an anti-reflux mechanism could be present in the total absence of any sphincter fibres and (2) that the oesophageal hiatus of the diaphragm was contributing to the high pressure zone.

Balloon Dilatation of Esophageal Strictures/Achalasia

“…Symptomatic gastroesophageal reflux occurs frequently after cardiomyotomy. 27,28 Antireflux surgical procedures are frequently performed at the same time as cardiomyotomy, especially when an abdominal route is used for the operation. 29 In our study, symptomatic gastroesophageal reflux was seen in only 4% of patients following dilatation and resolved spontaneously in all cases.…”

Treatment of Achalasia: A Review

“…The Mayo Clinic study in dogs suggested that reflux was more likely if a long myotomy was done (Ellis et al 1967), though Effier et al (1971, who routinely used a long incision, reported an incidence of reflux little higher than that at the Mayo Clinic. It has even been suggested that the gastro-oesophageal junction does not remain functional after cardiomyotomy and that competence of the cardia is maintained by other factors (Ellis et al 1967, Lobello et al 1978. Reflux causing heartburn is a considerable nuisance to a patient after cardiomyotomy, and responds poorly to medical therapy.…”

“…Such strictures are serious, for they respond poorly to medical therapy and bougienage, and while bile diversion operations may help (Holt & Large 1961), total oesophageal replacement may be necessary. Several series of surgical treatment show a sufficiently greater likelihood of subsequent reflux to render the results unsatisfactoryyet other series report no reflux problem, without any clear reason (though Lobello et al (1978) believe that careful preservation of 'the hiatal mechanism' is the reason). Stricture must be regarded as the most serious long-term consequence of therapy.…”

Cardiomyotomy associated with antireflux surgery in the treatment of achalasia

“…The efficacy of these valve-building operative techniques in the treatment of esophagitis is well established. Discussion continues concerning the results, and their efficacy in controlling the potential reflux diseases that are primarily characterized by disturbed motility, such as achalasia [3,11]. Controversy also exists about the danger of obstructive dysphagia after cardiomyotomy associated with antireflux surgery [12].…”