TUESDAY AFTERNOON, APRIL 19, 1977

2:00 P.M. Scientific Session Grand Ballroom

19. Cricopharyngeal Myotomy as a Method of Treating Pharyngoesophageal Dysphagia Secondary to Gastro-esophageal Reflux

R. D. HENDERSON and G. MARRY ATT*,

Toronto, Ontario, Canada

Food obstruction at the Cricopharyngeal level (Pharyngoesophageal dysphagia) is a common symptom of gastroesophageal reflux (51.3% of 1000 consecutive patients). In selected patients, Cricopharyngeal myotomy is effective in symptom relief. We have used myotomy in patients whose only symptom was dysphagia (2); and in patients too debilitated for major surgery (5);and in patients with persistent pharyngoesophageal dysphagia following hiatal hernia repair (12 out of 650).

All were investigated by barium esophagramme, endoscopy and manometry. 5 of 19 showed radiologic aspiration of barium. High speed manometric tracing showed intermittent Cricopharyngeal inco-ordination in the 6 consecutive patients most recently studied. This finding of incoordination has been shown to be present in 38 patients with reflux and in all with major Cricopharyngeal symptoms.

Myotomy was effective in relieving symptoms in both patients with this as their only reflux symptom and in the 5 patients too debilitated for major surgery. Good symptomatic improvement was obtained in 9 of 12 with persistent dysphagia following hernia repair, but in 3 relief was partial with persistent symptoms being secondary to distal esophageal obstruction.

Investigation is necessary to exclude other causes of dysphagia. However, with careful selection, myotomy has proved to be an effective method of treatment.

*By invitation

20. Complications and Failings of the Combined Collis-Belsey Operation

MARK B. ORRINGER* and HERBERT SLOAN,

Ann Arbor, Michigan

In the past 3 years, the Collis-Belsey operation has been performed in 82 patients. Thirty-three of these patients (40%) had undergone one or more previous operations at the esophagogastric junction; transthoracic (22) or transab-dominal (18) hiatal hernia repair; vagotomy (11); esophagomyotomy (5); or repair of an esophageal perforation (2).

In 4 of 15 patients, the combination of an esophagomyotomy and the Collis-Belsey reconstruction resulted in postoperative dysphagia which has required either chronic dilation (2) or esophagectomy and colonic interposition (2). In 2 patients who had had previous hiatal hernia repairs, mobilization of the extensively inflammed distal esophagus resulted in delayed perforation from a localized area of esophageal necrosis; both healed primarily following closure and reinforcement of the suture line with a pedicled intercostal muscle flap. One patient sustained an esophageal perforation during per-oral dilation of an esophageal stricture; attempted closure immediately at the time of the Collis-Belsey procedure failed and resulted in a chronic esophago-pleural-cutaneous fistula. A gastric fistula developed in 2 of 3 patients who required splenectomy because of intraopera-tive injury to the spleen; this closed spontaneously in 1 patient, but eventually resulted in the death of the other.

To date, 68 patients have had postoperative follow-up interviews and esophageal manometrics and acid reflux testing after 2-24 months (average 8.7 months). Clinically, 60 (88%) have had excellent or good control of gastroesophageal reflux, 3 have mild reflux but are greatly improved, and 5 have moderate to severe symptoms. With an intraesophageal pH electrode, however, moderate to severe gastroesophageal reflux has been detected in 17 patients (25%), 9 of whom emphatically deny symptoms of reflux, and 8 of whom have definite recurrent symptoms.

These data refute the concern expressed by others that ischemic necrosis of the gastroplasty tube in patients who have had prior operations at the esophagogastric junction is a frequent complication. They suggest, however, that the Collis-Belsey operation is not the best choice of an antireflux procedure when concomittant esophagomyotomy is required, and that the recent enthusiasm for the combined Collis-Belsey operation should be tempered by a cautious assessment of its long-term results.

*By invitation

21. Diffuse Spasm of the Esophagus: Clinical, Manometric and Surgical Consideration

HOWARD K. LEONARDI*, JOHN A. SHEA* and

F. HENRY ELLIS, JR., Boston, Massachusetts

Concern regarding the development of gastroesophageal reflux after extended esophagomyotomy for diffuse spasm of the esophagus (DSE) has influenced some to complicate the operation by adding a Collis-Belsey gastroplasty. Since we believe that a properly performed esophagomyotomy as proposed originally by one of us (FHE) relieves the symptoms in the majority of patients with DSE without the need for ancillary procedures, we have reviewed the clinical, manometric and surgical findings in 11 recent cases to shed further light on the controversy.

Substernal pain was the characteristic symptom in three of the 11. Dysphagia of variable degree was present in nine. Four patients had a small sliding esophageal hiatus hernia and two an epiphrenic diverticulum. Preoperative manometry determined the length of the myotomy and the lower esophageal sphincter (LES) was spared when normal. One patient whose lower sphincter was included in the myotomy developed medically manageable gastroesophageal reflux.

Esophageal manometry was performed in all patients. Hie disease involved the lower one-third of the esophagus in two, lower one-half in three and lower two-thirds in four. Themean maximum deglutitive pressure in the diseased area was 70 mm. Hg. The contractions were non-peristaltic, repetitive and spontaneous in most. Postoperative manometry in nine patients revealed a reduction in deglutitive pressures from a mean of 70 mm. Hg. to 20 mm. Hg. The mean LES pressure postoperatively was 13 mm. Hg. and was sufficient to prevent reflux in all but one patient.

*By invitation

22. Intra-Operative and Post-Operative Esophageal Mano-metric Findings with Collis Gastroplasty and Belsey Hiatus Hernia Repair for Gastro-Esophageal Reflux

J. D. COOPER*, S. GILL*, J. M. NELEMS* and F. G. PEARSON,

Toronto, Ontario, Canada

The combination of a Collis gastroplasty with a Belsey Mark IV fundoplication has proven clinically effective in the management of certain patients with complications of gastroesophageal reflux. The present study measured the effect of gastroplasty and Belsey repair on intraluminal pressure changes in the gastroplasty and lower esophagus. Manometric studies were performed on 8 patients who had gastroplasty and Belsey repair for reflux esophagitis. Measurements were performed using the MP-3 catheter which consists of 3 miniature pressure transducers spaced 5 cms. apart. Manometric studies were performed pre-operatively, intra-operatively and post-operatively. Intra-operatively the precise location of the tranducers could be determined by palpation through the wall of the stomach and esophagus. Post-operative studies were done with the aid of a fluoroscope so the transducer could be identified in relationship to the gastroplasty segment (which had been marked with radio-opaque clips at the time of surgery). At the time of operation the lower esophageal sphincter area was located manometrically and tagged with a marking suture. After creation of a 5 cm. gastroplasty tube, and again after completion of fundoplication, the transducers were advanced into the stomach and gradually withdrawn into the esophagus for pressure recordings. In each case the gastroplasty segment was immediately found to function as a high pressure zone. The pressure in this zone further increased following the fundoplication and this pressure could be diminished with intravenous Buscopan and augmented with intravenous Pentagastrin. The original, previously marked, lower esophageal sphincter was found in most instances to be included in the upper segment of the gastroplasty tube, but the entire length of the gastroplasty tube functioned as a high pressure zone and pressures in the tube were considerably higher than those originally present in the lower sphincter. The following Table gives the average pressures recorded in the eight patients:

	Pre-Operative	prior to gastroplasty	Intra-Operatively following gastroplasty	following fundoplication	Post-Operatively
					1wk	3mos.
Pressure (CM H20)	16	13	25	55	39	34

The Post-operative pressures were significantly greater than the pre-operative pressures (P<.05). Animal experimenls by others have demonstrated the ability of proximal gastric musculalure to funclion as a high pressure zone when converted into a lube or when wrapped around ihe esophagus. These sludies extend those findings to the human situation and provide a physiologic rationale for ihe effectiveness of gastroplasty and fundoplication.

3:30 P.M. Executive Session (Limited to Active and Senior Members) Grand Ballroom

*By invitation

TUESDAY EVENING, APRIL 19, 1977

7:00 P.M. President's Reception Dominion Ballroom

8:00 P.M. President's Dinner and Dance Dominion Ballroom

Attendance open to all physicians and their ladies. Tickets must be purchased at the registration desk by 5:00 P.M. on Monday, April 18th.

Dinner dress preferred.