Treatment of esophageal achalasia (cardiospasm) with diaphragmatic graft: report of 44 patients

Reconstruction of thoracic esophagus with pediculated diaphragmatic flap in dogs

PURPOSE

To verify whether pediculated diaphragmatic flaps were suitable to correct iatrogenic wounds in dog's esophagus injuries.

METHODS

Seven dogs were submitted to resection of a segment of the esophageal wall, which was then corrected by suturing a pediculated diaphragm flap. Endoscopic evaluation of the esophageal wall was done forty days after the surgical procedure.

RESULTS

Three animals died, one due to implant ischemia, caused by strangulation of the phrenic artery; other due to wound infection; and the last, due to mediastinitis. Scar retraction was observed, however, there was no stenosis, allowing the passage of a 9,8 mm probe with no difficulty. The limits between the implants and the native esophagus were indistinguishable, and the implant was covered by esophageal mucosa.

CONCLUSION

The diaphragmatic flaps are suitable on the restoring of continuity in dog's thoracic esophagus.

Surgical management of achalasia

Although achalasia is not a common illness in the United States and Europe, there continues to be a need for surgical therapy for treatment. Laparoscopic Heller myotomy and partial fundoplication has, for the most part, replaced open surgery (abdominal or thoracic) as the surgical treatment of choice. In order to perform this procedure well, one must select patients carefully, evaluate them fully, and adhere to the technical principles required to achieve consistently good results.

Pericardial repair after extensive resection: another use for the pedicled diaphragmatic flap

BACKGROUND

Extended resection for pulmonary malignancy frequently leaves a large pericardial defect, sometimes associated with resection of the phrenic nerve. On the left the defect does not require repair; as long as the defect is sufficiently large to avoid constriction, the heart can herniate freely. On the right such herniation is associated with venous inflow occlusion and death. The pedicled diaphragmatic flap has been used in other situations in thoracic surgery. We have modified this to allow closure of the pericardial defect and concurrent plication of the denervated diaphragm. It may also be used to cover the bronchial stump or a bronchial anastomosis.

METHODS

The flap has been used in 13 patients over an 11-year period.

RESULTS

Secure closure of the pericardial defect has been achieved in all patients with satisfactory plication of the diaphragm. Reoperation for bleeding was necessary in 3 patients, but in only 1 was the diaphragm shown to be the site of bleeding. Patients otherwise made an uneventful recovery.

CONCLUSIONS

A large pedicled flap of redundant diaphragm provides secure closure for large pericardial defects after extended right pneumonectomy.

Esophageal achalasia syndromes

Esophageal achalasia, characterized by failure of the lower esophageal sphincter to relax normally with swallowing and esophageal aperistalsis, may be primary or secondary to another disorder (in the United States most often cancer). Primary achalasia is of unclear etiology but almost certainly is a disorder of the innervation of the smooth muscle portion of the esophagus. This article reviews the classification and clinical features of achalasia syndromes, as well as current concepts of pathogenesis, diagnosis, complications, and therapy of this group of disorders.

Heller's myotomy for achalasia: is an added anti-reflux procedure necessary?

Literature review (1970-85) indicates excellent or good results following Heller's operation in 89 per cent of 5002 patients. The overall mortality was 2.8 per cent with a reoperation rate of 2.8 per cent. When the operation was done through an abdominal incision, gastro-oesophageal reflux was almost twice as common as when it was done through a thoracic incision, regardless of whether an anti-reflux procedure was performed.

Achalasia in children: treatment by anterior esophageal myotomy (modified Heller operation)

Although rare in children, achalasia can be the cause of debilitating symptoms and growth retardation. During a 4-year period, six patients (mean age 9.9 years) underwent a modified Heller operation (anterior esophageal myotomy) without complication. A concomitant modified Belsey fundoplication was performed in three patients who were judged at the time of operation to be at high risk for postoperative gastroesophageal reflux. Preoperative symptoms of dysphagia, postprandial vomiting, retrosternal pain, and pulmonary complications were eliminated in all patients. Follow-up interviews seven to 48 months (mean 23 months) following operation revealed normal diet and normal growth in all six children, with no recurrence of preoperative symptoms or evidence of gastroesophageal reflux. Technical details which we believe contribute to success in the operative management of pediatric achalasia include the transthoracic approach and the selective performance of complementary anti-reflux procedures.