The surgical treatment of cardiospasm

Abstract

GENERAL CONSIDERATIONS.THE most unsatisfactory chapter in the surgery of to-day is that of the treatinent of oesophageal obstruction. The grave discomfort of being unable to swallow, the frequency with which the obstruction is due to carcinoma, the inaccessibility of the oesophagus, and the consequent unsatisfactory results of surgical treatment, make this the most dreaded of all diseases. Fortunately therc is quite a definite proportion of cases where the obstruction is not due to carcinoma and can be completely cured if recognized. Since, however. these cases also are fatal if overlooked, it becomes of extreme importance to recognize and to treat them as early as possible.The most important of these non-malignant obstructions is that curious condition most often described as cardiospasm. It has also been known as idiopathic dilatation of the ccsophagus, achalasia of the cardia, hiatal esophagismus, arid ccsophagectasia. This lesion, which appears to have been first described by Ziemssen and Zenker in 1874, has excited much interest since attention was more i'ully directed to it by Mikulicz in 1581. In the many accounts, often of few or isolated cases, which have since followed tlicre is 110 doubt that a considerable number of different lesions have bcen described.It is thus essential that some clear definition of the condition should be gi\-en ; all the cases would be included under the following : " A condition of dilatation and hypertrophy of the ccsophagus where, on post-mortem examination, no obstruction can be found distal to the dilatation." This will exclude all cases of hysterical spasm in young men and women : these do not show any hypertrophy and dilatation, and yet it is evident from the literature that they are often confused with cardiospasm, which is a discase more cornmonly of middle or advanced age.The hypertrophy and dilatation which is not infrequently scen with carcinoma or other obstruction of the lower end of the esophagus clearly docs not come into this category, but it is not so generally realized that obstruction at the pylorns may also be associated with dilatation of the esophagus. Cases ha\-c. for instance, bcen reported by EhlcrslO where there was eimrmous hypertrophy of the cesophagus with congenital pyloric obstruction, and by Pritchard a~i t l Hillier47 where there was a similar pyloric lesion and also coiistrictiori a't the ilcocxcal d v c . It is vevy possible that in both these cases the msophageal lesion was secoritlary to the pyloric obst,ruction, for Hutchison27 demonstrated that with congenital pyloric stenosis the hypertrophy and dilatation not uncommonly exteiidcd to the cesopha,gus. This is clearly shown by an investigation of post-morteni specimens. The records of the London Hospital postmortems have heen carefully iiir-estigated for mc by Mr. Hamilton Hailey,

Operative manometry and endoscopy during laparoscopic Heller myotomy

“…Achalasia was more fully described by Ziemssen, Zenker, and Mikulicz in the 19th century [6,20]. Since that time, various nonsurgical therapies have been employed to treat this disease, including esophageal dilation, oral nitrates, calcium channel blockers, and the injection of botulinum toxin directly into the lower esophageal sphincter.…”

Achalasia—If Surgical Treatment Fails: Analysis of Remedial Surgery

“…Freeman 44 frequency of muscle atrophy in the vicinity of fibrosis between the two layers, although the usual interpretation is that such atrophy is merely a late response to esophageal retention, following a period of compensatory muscular hypertrophy. 45,46 Goldblum et al 47 showed a secondary degeneration and fibrosis in 29/42 esophageal resectates with achalasia. Our own recent analyses of biopsies taken from the high pressure zone of the distal esophagus in patients undergoing surgery for achalasia revealed an association between the duration of symptoms prior to the operation and the degree of fibrosis.…”

The late results of Heller's operation for cardiospasm

“…It was Sir James Walton (1925) who divided cardiospasm into two clinical types, the painful and the painless. It is probable that spasm may be the cause of the pain, for oesophagitis and peptic ulceration cannot be demonstrated in all these cases.…”