Gut, 1965, 6, 80

Reflux after cardiomyotomyFRANK ELLIS AND F. L. COLE

From the Departments of Surgery and Radiology, Guy's Hospital, London

EDITORIAL SYNOPSIS A series of 56 patients with achalasia of the cardia included 16 with refluxafter operation of whom seven were symptomless. A radiological technique which facilitated thedetection of reflux was employed.The factors contributing to the development of reflux included duodenal ulceration, previous

oesophageal operations, double and strip myotomies, and disruption of the hiatus. Of nine patientswith reflux oesophagitis, five required further operative treatment. Careful pre-operative evaluationand the preservation of the hiatal mechanism are considered to be the most important factors inreducing the incidence of reflux. The long myotomy is considered to be necessary to ensure adequateoesophageal drainage. If it is placed on the lesser curve side of the oesophagus and stomach therisk of reflux is likely to be diminished.

The return of achalasia-like symptoms after cardio-myotomy may be due either to an inadequatedivision of the circular muscle fibres of the lowersegment or to gastro-oesophageal reflux through acardia rendered incompetent by the operation andthereby allowing oesophagitis, ulceration, andfibrosis to occur. Although the incidence of post-operative gastro-oesophageal reflux varies widely,there is general agreement that it is important todistinguish between a true recurrence of theachalasia and reflux oesophagitis because the twoconditions need different management. Douglasand Nicholson (1959) found two reflux stricturesamong 41 cases of cardiomyotomy whereas Nemirand Frobese (1962) recommended the addition ofpylorotomy to cardiomyotomy following an inci-dence of 40% reflux among their early cases.Atkinson (1959) investigated the pressure in thelower oesophageal segments of 18 patients who hadbeen subjected to cardiomyotomy and in whomsubsequent reflux was suspected on clinical grounds.In the majority the resting pressure was found to belower than normal but only five had demonstrablereflux. Among 61 patients subjected to cardio-myotomy Barlow (1961) found 15 with some degreeof reflux and six with strictures.A long pre-operative history of oesophageal

symptoms is often present in patients subjected tocardiomyotomy. If, after the operation, refluxproduces further symptoms they do not tend tocomplain as readily as those suffering from suchsymptoms for the first time. The evasive features ofthe clinical picture are further complicated bydifficulty in detecting reflux radiologically or

endoscopically. This difficulty is primarily due tothe fact that, despite treatment, the oesophagus inachalasia not uncommonly contains some residue.Unless special measures are taken to empty thedilated segment, the contrast material remainingabove the cardia following a barium meal willobscure the region to such an extent that refluxfrom the stomach may not be seen. In the same waythe detection of reflux on oesophagoscopy will behampered by the presence of residue and by themechanical difficulties of visualizing the lower endof the oesophagus.

This paper reports the results of an investigationinto the incidence, causes, and effects of refluxfollowing cardiomyotomy. From 1943 to 1963cardiomyotomy was carried out in 56 patients.Table I shows the status of these patients in 1963.Forty-five were reviewed clinically and radio-logically in 1963, five were last reviewed similarly in1956, three were dead, and three untraced. Of thetotal of 56, 17 were found to have radiologicalreflux. One of the patients who died developed agross stricture following first a Mikulicz operationand then a cardiomyotomy. Finally her symptoms

TABLE I

Follow-up

STATUS OF 56 PATIENTS SUBJECTED TOCARDIOMYOTOMY DURING 1943-1963

No. of Cases No. With Reflux

To 1963To 1956 onlyDeadNo follow-upTotal

80

45533

56

1511

17

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Reflux after cardiomyotomy

were relieved for three years before her death byileocaecal transposition.The mean interval from the time of cardio-

myotomy to follow-up was eight years, the rangebeing two to 20 years. Most of the operations werecarried out through the chest and in most cases a'long' single anterior myotomy was extended fromthe oesophagus on to the stomach.

DETECTION OF REFLUX

RADIOLOGICAL TECHNIQUE The symptoms of reflux inthese patients proved to be so diverse that attempts toforecast its presence before screening were, except ingross cases, highly inaccurate. Using image intensifica-tion and television screening a radiological techniquewas designed to overcome the difficulties of visualizinggastroesophageal incompetence in the presence ofincomplete emptying of the oesophagus.

After preliminary fasting each patient was given athird of a litre of barium and 10 minutes later theoesophagus was screened. While many of the patientshad little or no oesophageal delay, in nearly half thereremained in the oesophagus sufficient barium to interferewith the detection of reflux by the usual methods. Ifsufficient time was allowed to elapse in order to allow theoesophagus to empty, most of the barium was found tohave left the stomach and insufficient remained todetect reflux. This difficulty was overcome by givingeach patient water to drink until the residual bariumpassed into the stomach leaving the lower oesophagusradiotranslucent. In most cases about one-third of alitre of water was necessary and the oesophagus was freeof barium within a few moments. The patient was thenplaced in the Trendelenburg position and reflux of bariumwas sought by applying external pressure over thestomach with the patient first supine and then prone.Figure Ia shows a residual column of barium in apatient entirely free of symptoms eight years aftercardiomyotomy. After drinking water (Fig. lb) theoesophagus was virtually empty. When the patient wastilted head-down the reflux which occurred (Fig. lc) wasreadily detectable whereas it could easily have escapednotice if the barium residue had still been present.The second point in the technique is one for which we

are indebted to Mr. Hermon-Taylor. It was found that

several of the patients in whom no reflux occurred whenthe usual postural methods were used, had a slow'trickle-back' of barium which was only revealed whenthey were allowed to relax for 10 minutes in the Trendelen-burg position. By using these two additions to the usualmethods of radiological detection of reflux, gastro-esophageal incompetence which would have otherwiseescaped notice was detected. Of the 45 patients screenedin 1963, 15 were found to have reflux.

CLINICAL FEATURES Without prior knowledge of theradiological appearances all the patients were interviewedby one observer. They were questioned closely about thesymptoms of heartburn and regurgitation both beforeand after cardiomyotomy. The patients were thenscreened by the other observer without detailed know-ledge of the clinical features. Having established the radiological competence of the gastro-oesophageal sphincterthe clinical features of the whole group were reviewedwith special reference to symptoms of reflux. Twoanomalies were found. 1 Among 30 patients withoutreflux, eight had occasional heartburn and regurgitation.2 Among 16 patients having reflux (Table II), sevenhad no symptoms and were classed as having good orexcellent results from the operation, five had pain andregurgitation while the remaining four had gross stricturesaccompanied by all the features of oesophageal obstruc-tion.

RESULTS

These findings suggest that heartburn and regurgit-ation, the usual hallmarks of gastro-oesophagealincompetence, are not reliable indicators of refluxin patients with achalasia. The lack of correlationbetween clinical and radiological findings is a well-known feature of this disease in all its stages, andthe data in this group of patients emphasize that,for the proper evaluation of the gastro-oesophagealjunction after cardiomyotomy, there is no substitutefor careful radiology.

FACTORS PREDISPOSING TO REFLUX Table II showsthat in eight of 16 patients with radiological reflux,

,LE IICLINICAL FEATURES OF PATIENTS WITH RADIOLOGICAL REFLUX AFTER CARDIOMYOTOMY

Patients Factors Predisposing to Reflux Effect of Reflux Subsequent Treatment Present Status

1-7 Anterior and posterior incisions ........1Muscle strip excised ................ 1 NonePrevious cardiomyotomy ............ 1None .............................. 4

8 None Pain and regurgitation9 None Pain and regurgitation10 None Gross strictureII None Gross stricture12 Previous Mikulicz operation Pain and regurgitation13 Hiatus hernia Gross stricture14 Duodenal ulcer Gross stricture15 Duodenal ulcer Pain and regurgitation16 Pneumonectomy Pain and regurgitation

None No symptoms

AntacidsAntacidsDilatationIleocaecal transpositionIleocaecal transpositionHernia repairedOesophagogastrectomyAntacidsAntacids

Symptoms controlledSymptoms controlledSevere symptomsNo symptomsDeadModerate symptomsRecent further resectionSymptoms controlledSymptoms controlled

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11G'. I a.

FIG. iC.

FIG. 1. Techniique jor detecting gastro-oesophageal in-competence in the presence of delay in emptying of theoesophagus. The residue of bariuim (la) is washed inito thestomach by drinkinig water (lb) thereby allowing thedletectiont of reflux (Ic) by the uisutal methods.

FIG. Ib.

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FIG. 2a.

FIG. 2b.FIG. 2. The effects of reflux after cardiomyotomy in apatient with achalasia who also had a duodenal ulcer. Anulcer crater (2a) developed and was followed by completeoesophageal stenosis (2b).

there were possible explanations for the presence ofreflux after cardiomyotomy. Four patients had morethan the modified Heller's operation which isperformed at present. Of these one had anterior andposterior incisions, one a strip of muscle excised,

and two had been subjected to previous sphincter-destroying operations. Of the four remainingpatients two had duodenal ulcers, one a pneumo-nectomy, and one a hiatus hernia.

SUBSEQUENT TREATMENT AND PROGRESS Sevenpatients had no symptoms and were classed ashaving good or excellent results. Four had moderatesymptoms which were controlled by antacids. Fiverequired further surgical treatment having developedsevere oesophageal obstruction. They were subjectedto a variety of procedures (Table II). In all cases,except case 11 in whom no symptoms are presentbut reflux still occurs freely, the results wereunsatisfactory and having each had two operationsthese patients were more severely incapacitatedthan by the original achalasia. Figure 2a shows anoesophageal ulcer which developed with refluxthree years after cardiomyotomy. The patient wassubsequently shown to have a duodenal ulcer. Later(Fig. 2b) gross oesophageal stenosis occurred.

DISCUSSION

Among the 45 patients followed to 1963 there were12 in whom the results of cardiomyotomy wereunsatisfactory. In no less than seven of these refluxwas responsible for the recurrence. This means thata substantial proportion of the failures followingcardiomyotomy could be eliminated by the preven-tion of post-operative reflux. However, since sevenpatients with reflux had no symptoms and haveremained well for many years following operation,it is evident that reflux and reflux oesophagitis arenot synonymous.The problem of reflux after cardiomyotomy

appears in some respects to be a surgical impassebecause an operation which produces adequateoesophageal drainage may so lower the competenceof the gastro-oesophageal sphincter that reflux isinevitable. This is more likely to occur in thosepatients in whom the lower oesophageal sphincter(as opposed to the other mechanisms) is the mostimportant factor contributing to competence. Anoperation which fails to achieve complete divisionof the circular muscle will almost certainly notensure adequate oesophageal drainage thoughreflux is less likely to occur. This impasse may bepartly resolved by careful selection of patients andby careful attention to detail during operation.

SELECTION OF PATIENTS The experience from thisgroup of patients shows that the only two patientswith duodenal ulcers developed reflux oesophagitis.It is important to avoid cardiomyotomy in suchpatients, particularly if they have gastric retention.

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84 Frank Ellis and F. L. Cole

In addition to pre-operative radiological examinationfor duodenal ulcer, it may also be advisable toestimate the acid production of the stomach. If thisis high, even in the absence of duodenal ulceration,it is possible that ifreflux occurs after cardiomyotomyoesophagitis will tend to develop more readily thanin a patient with normal acid production. Thepresence of inflammatory changes in the oesophagealmucosa should arouse suspicion that reflux may bepresent even before operation and the patientinvestigated accordingly. The previous explorationof the lower oesophageal segment which had beencarried out in two of the patients with reflux suggeststhat incompetence may occur more readily aftersuch procedures.

OPERATIVE TECHNIQUE McVey, Schlegel, and Ellis(1963) have shown that in animals the characteristichigh pressure zone in the lower segment is diminishedor abolished following cardiomyotomy. Atkinson(1959) has shown a similar effect in man. The effectin animals is greater with the classical doubleHeller myotomy and with the 'long' myotomy thanwith the 'short' in which the incision is stopped atthe oesophago-gastric junction. However, there islikely to be less adequate drainage with a shortincision. It is possible that the free reflux which mayoccur with the long incision extended on to thestomach is due to division of the oblique sling ofmuscle fibres (sling of Helvetius) which help tomaintain the mucosal rosette. The fibres can beavoided by making the incision on the right side ofthe oesophagus and extending it down the lessercurve rather than on the anterior surface of thestomach.A most important operative principle in main-

taining the delicate balance between procedureswhich ensure free oesophageal drainage withoutallowing reflux to occur and those which result ingastro-oesophageal incompetence is the preservationof the hiatal mechanism. Excessive mobilization ofthe oesophagus, division of the phreno-oesophagealligaments, displacement of the stomach into the

chest, and failure to restore the lower segment of theoesophagus to its position below the diaphragm allcontribute to weaken the hiatal mechanism therebyproducing sufficient imbalance to allow reflux tooccur. If such defects are unavoidable a repairshould be carried out after the myotomy has beenestablished. Avoidance of damage to the vagus isimperative because post-operative gastric retentionmay result in reflux. In view of the accumulatingevidence that reflux occurs alongside nasogastricsuction tubes these are also probably best avoided.

Finally it has been suggested that cardiomyotomyshould be accompanied by additional procedures toprevent reflux. Suturing the fundus of the stomach tothe diaphragm (Barlow, 1961), pyloroplasty, andgastroenterostomy (Hawthorne, Frobese, and Nemir1956) have been described. It would appear thatthese additions to the operation impose an un-necessarily heavy burden on the patient, but theymay merit attention where duodenal ulceration andachalasia coexist. For the remainder, carefulattention to operative detail will do much to reducethe small proportion of unsatisfactory results whichfollow cardiomyotomy. Radiological assessment inthe immediate post-operative period and after aninterval of six months will probably reveal a smallnumber in whom reflux occurs despite adequateprecautions.

These patients need long-term supervision beforeit is evident how much difficulty the reflux will cause.

REFERENCES

Atkinson, M. (1959). The oesophago-gastric sphincter after cardio-myotomy. Thorax, 14, 125-131.

Barlow, D. (1961). Problems of achalasia. Brit. J. Surg., 48, 642-645.Douglas, K., and Nicholson, F. (1959). The late results of Heller's

operation for cardiospasm. Ibid., 47, 250-253.Hawthorne, H. R., Frobese, A. S., and Nemir, P., Jr. (1956). The

surgical management of achalasia of the esophagus. Ann. Surg.,144, 653-669.

McVey, J. L., Schlegel, J. F., and Ellis, F. H., Jr. (1963). Gastro-esophageal sphincteric function after the Heller myotomy andits modifications. Bull. Soc. int. Chir., 22, 419-423.

Nemir, P., Jr., and Frobese, A. S. (1962). The modified Heller opera-tion for achalasia of the esophagus. Surg. Clin. N. Amer., 42,1407-1418.

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