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POSTGRAD. MED. J. (I963), 39, 290
FUNCTIONAL DISEASE OF THE OESOPHAGUSRONALD BELSEY, M.S.,
F.R.C.S.
Surgeon-in-Charge, Thoracic Unit, Frenchay Hospital, Bristol;
Consultant in Thoracic Surgeryto the South West Region
THIS term is used to embrace all those causes ofdysphagia
dependant upon a disorganization ofthe normal, co-ordinated,
neuro-muscular functionof the oesophagus. All forms of dysphagia
due toorganic stenosis of the gullet, obstruction of itslumen by
foreign bodies, or compression byextrinsic pressure are
excluded.
Consideration of the causes of functionaldysphagia is
complicated by a lack of certainty inour knowledge of the normal
activity of the gullet.This organ is not a mere inert drainpipe
orpassive conduit. Not only does it function withefficiency and
consistency as a pump to propelthe bolus or fluid from mouth to
stomach undernormal conditions in man, but can also overcomethe
forces of gravity, as demonstrated by thesportsman who, for a
wager, imbibes a pint ofbeer whilst standing on his hands in the
invertedposition. Anyone who has witnessed a giraffe inthe act of
drinking will appreciate the dynamicpropensities of this organ.
Peristalsis, as normally accepted, probably doesnot occur in the
oesophagus.The oesophagus is essentially a muscular tube
with a sphincteric mechanism at both ends. Thelumen normally
contains a small quantity ofsaliva, and a larger quantity of air
under a mildnegative pressure reflecting and varying with
thenegative pressure in the pleural cavities. Thesphincter at the
upper end is controlled by thecricopharyngeal muscle in a state of
tonic contrac-tion. The vigilance of this sphincter is testifiedby
the infrequency with which sudden inversionis accompanied by
regurgitation of oesophagealcontents. Were it not so, then every
patient withachalasia of cardia and a resting oesophagealresidue of
up to two pints, or more, of fermentingfood would run the risk of
drowning every night.During normal deglutition the upper
sphincterrelaxes as the pharyngeal muscles voluntarilypropel the
bolus from the mouth. The lowersphincter is more complex. There is
considerabledoubt as to whether any intrinsic sphinctermechanism
exists. Probably the control of gastro-
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BELSEY: Functional Disease of the (Esophagus
spasm at any point. Failure of the lower end ofthe gullet to
relax during swallowing leads to thewell-known condition of
achalasia, with diffusehypertrophy and dilatation of the whole
organ.
Failure of the lower sphincter and the reflux ofgastric
secretion into the esophagus is the essentialfunctional disturbance
responsible for most ofthe symptoms in hiatus hernia, and will not
beconsidered further in this communication.
Finally, a rare form of dysfunction in whichacute spasm of the
mid-third of the organ accom-panies the attempt to vomit large
quantities offood and fluid after an alcoholic debauch, maylead to
a rise in intra-luminal pressure sufficientto result in spontaneous
rupture of the lowerthird with catastrophic results.
This communication is mainly concerned withthe management of the
three commoner forms offunctional dysphagia amenable to surgical
treat-ment-spasm of the upper sphincter, 'corkscrewesophagus', and
achalasia of the cardia. The 132cases reviewed were all admitted to
a RegionalSurgical Thoracic Unit under the care of onesurgeon over
a period of 20 years. The reasonfor investigation was either
dysphagia or thepulmonary complications of oesophageal
dysfunc-tion. Non-surgical functional disorders, such asthose due
to basilar artery thrombosis ormyasthenia gravis, will not be
considered furtheralthough they complicate the problem
ofdifferential diagnosis.
TABLE IRELATIVE FREQUENCY OF THREE PRINCIPAL FORMS
OF FUNCTIONAL DISORDER(i) Upper oesophageal spasm, with
pouch
formation .. .. .. .. 20(ii) Corkscrew oesophagus .. .. I8(iii)
Achalasia of cardia .. .... 94
Achalasia of Pharyngo-Esophageal Junctionwith Pouch
Formation
Globus hystericus has been a popular diagnosisin any case where
intermittent symptoms ofdysphagia have been referred to the
cervicaloesophagus. In fact, the majority of these patientsare
suffering not from hysteria but from organicobstruction of the
cervical oesophagus by muscularspasm, or achalasia, in the region
of the pharyngo-cesophageal junction (Fig. I). The spasm may
besufficiently severe to lead to the formation of apulsion
diverticulum through the posterior wallof the pharynx. When the
patient presents withthe well-established picture of a
pharyngealdiverticulum, the underlying obstructive elementis
usually overlooked, and completely ignored inplanning treatment.
This omission undoubtedlyaccounts for the unsatisfactory results of
treatmentand the high incidence of recurrent diverticulum
FIG. I.-Severe spasm of the cervical oesophagusDysphagia
relieved by myotomy.
Iformation. Attention is diverted from the under-lying cause of
the dysphagia by the bizarreradiological manifestations of the
sequelse. Thediagnosis is made largely on the symptoms,
thelocalization of the obstruction, the radiologicaldemonstration
of a zone of persisting spasm in thisarea, and the exclusion of
other possible causesof obstruction. A barium swallow
examinationmay reveal a small pulsion diverticulum of thelower
pharynx, too small to be able to contributeto the dysphagia.
(Esophagoscopy will contributelittle to the diagnosis except to
exclude otherpossible causes for the symptoms, e.g. a
malignantstricture. Apart from the distress caused by thedysphagia,
the importance of this lesion lies in thefact that it is the
precursor and cause of apharyngeal diverticulum. Before the onset
of thiscomplication the dysphagia is variable, andinfluenced by
emotional stress-hence the term'globus hystericus'. Once a pouch
has developedand assumed a dependant position the symptomsincrease
in severity and are more constant. Thesesymptoms are well
recognized and will not beelaborated here, except to stress the
frequencywith which these patients present with chronic orrecurring
aspiration pneumonitis due to thenocturnal inhalation of the debris
that mayaccumulate in the pouch.The development of a pulsion
diverticulum is a
reversible process in its early stages, and relief of
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POSTGRADUATE MEDICAL JOURNAL
FIG. 2.-(a) Spasm of the cervical esophagus with early pulsion
diverticulum. (b) Followingmyotomy; the spasm and dysphagia have
been relieved and the diverticulum has disappeared.
I
FIG. 3.-Pulsion diverticulum of the pharyngo-cesophageal
junction. The diverticulum disappearedcompletely following an upper
cesophageal myo-tomy.
FIG. 4.-Lipiodol accumulating in the mediastinumfollowing
instrumental perforation of a pharyngealdiverticulum. Spontaneous
healing occurred, andat a later date successful myotomy and
diverticulo-pexy were carried out.
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BELSEY: Functional Disease of the (Esophagus
/3 Ho!...FIG. 5.-(a) Pharyngeal diverticulum.
cesophageal myotomy.
the obstruction may lead to rapid disappearanceof the pouch
(Fig. 2). Hence the importance of earlyrecognition of this
condition and its promptrelief.Negus (I950) has advocated
dilatation of the
spastic pharyngo-oesophageal junction, repeated asnecessary.
Even in the hands of an expert,endoscopic dilatation of the
cesophagus is notdevoid of risk of perforation or abrasion of
thegullet, the risk being directly proportional to thefrequency
with which it has to be performed.If the dysphagia recurs after the
initial dilatation,then other methods are indicated. That
preferredby the author consists of an extramucous myotomysimilar to
the classical Heller operation performedon the lower oesophagus for
the relief of achalasia.A vertical myotomy incision is made over
theantero-lateral aspect of the lower half-inch of thepharynx and
the upper two inches of the cervicalesophagus, usually on the right
side. Thisprocedure has proved satisfactory and has led tothe
disappearance of early diverticula (Fig. 3).
It is logical to assume that destruction of thesuperior
oesophageal sphincter might expose thepatient to the hazards of
recurring aspirationpneumonitis. Provided that one of the
cesophagealsphincters remains competent, in practice therisk
appears to be small, and no instance has beenencountered so far in
this small series. In factthere has been in this series no instance
of'oesophageal breathing' as anticipated by Negus(1950) in
discussing the principles of thisprocedure.Once a pulsion
diverticulum larger than a
grape has developed then dilatation becomes evenmore dangerous
owing to the difficulty of gainingaccess to the lumen of the
esophagus beside theneck of the pouch and the risk of perforating
the
(b) Following diverticulopexy and
FIG. 6.-'Corkscrew oesophagus' associated with aType I hiatus
hernia.
bottom of the pouch and causing mediastinitis(Fig. 4). In
addition to the myotomy alreadydescribed, either excision of the
pouch, or itsinversion and suture to the anterior
longitudinalligament of the cervical spine in the up-endedposition
is necessary. The latter method has beenused by the author in i8
cases with completerelief of symptoms and no recurrence of thepouch
formation. It is preferred to excision
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...... 1rJ i: ]:~ ?" ::?:',~i ~~~~~ ¢,i~.......... ... ..
............ . .... . ........... ............ ..J
FIG. 7.-(a) 'Corkscrew esophagus' with a small diverticulum of
the lowerthird. (b) Following Heller's operation. Dysphagia
completely relieved,but the diverticulum persists.
owing to the risk of a salivary fistula and thedifficulty of
performing a satisfactory repair ofthe thin posterior pharyngeal
wall.A direct attack on the pouch with no attempt
to relieve the underlying cause will fail to relievecompletely
the dysphagia and will be followed bya high rate of recurrent pouch
formation (Fig. 5).The longest follow-up period following
myotomyand diverticulopexy has been ten years in thisseries. As yet
there has been no recurrence of thepouch formation or
dysphagia.Diffuse (Esophago-spasm
This condition is commoner in the lower halfof the oesophagus.
It is not peculiar to anyparticular age group or sex. It occurs in
twoforms-primary and secondary. The primaryform appears to be
closely allied to achalasia of thecardia in that examination of the
oesophagusreveals diffuse muscular hypertrophy indis-tinguishable
from that which characterizes thelatter condition. The secondary
form is frequentlyassociated with the presence of a hiatus
herniaand gastro-oesophageal reflux (Fig. 6). The
assumedassociation between the two is based upon theobservation
that surgical control of the gastro-cesophageal reflux leads to
relief of the spasticcondition of the gullet. The degree of
muscularhypertrophy is less in the secondary form.The radiological
appearances presented by this
condition are bizarre and have acquired thedesignation of
'corkscrew oesophagus'. A seriesof contraction rings occurs
intermittently through-
out the lower half of the oesophagus. They havenot been observed
above the level of the aorticarch. The rings always occur at the
same levels,and are not produced by an exaggerated form
ofperistalsis. Solitary or multiple pulsion diverticulaare commonly
associated with this form ofcesophago-spasm and are undoubtedly
'blow-outs'occurring in the zones of increased
intra-luminalpressure.Much of our knowledge of the abnormal
physiology of this condition has been elucidatedby Good (working
at the Mayo Clinic), by meansof serial pressure recordings from
balloons locatedat various levels in the gullet. By this
methodpressure changes at various points within thelumen can be
recorded during swallowing and atrest, and the disordered activity
of the gullet corre-lated withthe symptoms. The commonest symptomof
this condition is dysphagia, but in some casesthe presenting
symptom is chest pain of ananginal distribution. During swallowing
the con-traction of the various spastic zones or rings mayoccur in
one of two ways: either synchronously,or progressively from above
downwards. In theformer instance the presenting symptom is
dys-~phagia; in the latter, substernal chest pain.The indication
for surgical treatment in this
condition is the severity of the symptoms. Thepresence of
pulsion diverticula in the lower'oesophagus rarely aggravates the
symptoms andin contrast to those at the
pharyngo-aesophagealjunction, these do not need surgical
treatment,except in the rare instances when they develop
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BELSEY: Functional Disease of the (Esophagus
FIG. 8.-(a) Achalasia of the cardia complicated by gross
oesophageal dilatation.Note fluid level above the right clavicle.
(b) Two years following modifiedHeller's operation. (Esophageal
dilatation persists, but there is now noretention of fluid in the
organ.
to a large size, and cause extrinsic pressure on thegullet below
the level of the origin of the diverti-culum (Fig. 7). Dilatation
is rarely of value in thiscondition and if diverticula are present
can bedangerous. Relief of the dysphagia can be achievedby a Heller
type of myotomy performed on thelower oesophagus as in the
treatment of achalasiaof the cardia. A vertical extra-mucous
myotomyincision is made over the lower three inches ofesophagus at
least, and extended for a furtherhalf inch over the cardia of the
stomach to ensurethat all the circular muscle fibres of the
lowercesophagus have been divided. If a hiatushernia is present
this should be repaired and afunctioning valvular mechanism
restored to thecardia to prevent any further
gastro-cesophagealreflux. Minor degrees of aesophagospasm
arefrequently encountered complicating reflux andeffective control
of this reflux leads to prompt andcomplete relief of the spasm.
Excision of pulsion diverticula of the loweroesophagus, on the
mistaken assumption that theyare responsible for the patient's
symptoms,without relief of the functional obstruction willlead to
catastrophic and often fatal complicationsin the form of
broken-down suture lines andmediastinal and pleural
suppuration.Achalasia of the CardiaThe cause of this condition
remains obscure.
Commonly the obstruction is confined to thecardia but in the
early stages of the conditionthere may be diffuse spasm of the
lower half of theorgan; in the later stages this is superseded
bydiffuse progressive dilatation and lengthening of
the organ. The irregular spasm already describedas 'corkscrew
oesophagus' may be associated withachalasia and there appears to be
a close patho-logical affinity between the two conditions.However,
pulsion diverticula are rarely seen inachalasia. There is diffuse
uniform hypertrophyof the muscle layers of the oesophagus,
maximalin the lower half.At the cardia, the point of obstruction,
the
architecture of the muscle layers suddenlybecomes normal and in
this region there is nohypertrophy, supporting the thesis that
theobstruction is due to failure of normal relaxationrather than
true spasm. Pathological changeshave been observed in the nerve
plexes in themuscle layers but whether these are primary
orsecondary, congenital or acquired, is not known;nor is their
significance in the aetiology of thiscondition. In longstanding
cases the degree ofdilatation or mega-oesophagus that develops
isprodigious and this undoubtedly jeopardizes thefunctional result
following surgical relief of theobstruction. Moderate dilatation
will disappearfollowing operation; gross dilatation will
diminishbut some degree will remain permanently (Fig.
8).Considerable quantities of ingested food andfluid, some taken
several days previously, arecommonly retained in the dilated
gullet. In theerect position a fluid level can be seen in theregion
of the clavicles on radiological examination.Conditions are ideal
for alcoholic fermentation,a fact which may explain the unnatural
euphoriaenjoyed by many patients suffering from thiscondition. Of
greater importance is the diffuseretention oesophagitis that may
occur in advanced
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POSTGRADUATE MEDICAL JOURNAL
cases. The mucosa is then reddened and oedema-tous, and has a
characteristic granular appearance,bleeding readily if touched.
There is no resemb-lance to the oesophagitis caused by
gastro-oesophageal reflux. The significance of theoesophagitis is
twofold. First, it appears to be adefinite pre-malignant condition;
reference tothis will be made later. Second, the presence ofgross
retention oesophagitis is a contra-indicationto radical surgical
treatment and some preliminaryform of drainage is necessary to
control it beforeany form of Heller procedure is attempted,owing to
the risk of perforation or spontaneousrupture of the softened
oedematous mucosa whosetexture can rightly be likened to that of
theproverbial wet blotting paper.Diagnosis
Although dysphagia is the presenting symptomin approximately 90%
of cases, the patient maycome under observation in other ways.
Thedysphagia is of such long duration, and so insidiousin onset and
progress that the patient may accepthis disability as natural and
inevitable. Only byasking leading questions can the clinician
elicita true picture of the patient's disability. Thesepatients are
often diagnosed as hysterical in theearly stages before obvious
dilatation of thegullet has occurred. Four patients with
achalasiawere referred to the author from mental hospitalswith a
diagnosis of chronic depression and 'anoesophageal abnormality'. On
questioning it waslearnt that the patients were depressed
merelybecause they could not swallow. Relief of thedysphagia
resulted in a dramatic psychiatric cure.Pulmonary complications due
to recurring
aspiration pneumonitis, following regurgitation ofoesophageal
contents at night when the upperoesophageal sphincter is caught off
its guard, arecommon, and may result in extensive,
diffuse,pulmonary fibrosis. The dyspnoea and pulmonarysymptoms then
overshadow the dysphagia. It issurprising that more patients do not
drown intheir own cesophageal residue. The youngestpatient in the
author's series, a boy of 8 years, wasadmitted to hospital with a
diagnosis of bron-chiectasis for further investigation. It was
thenoise caused by the aspiration of fluid into thetrachea and
bronchi at night that led to thecorrect diagnosis. As long ago as
I943 Hurstdescribed four cases with respiratory
complicationsfollowing regurgitation, and a fifth, fatal, case
ofasphyxia.
Achalasia may be brought to light as the resultof a routine mass
miniature radiography examina-tion. The opaque, fluid-filled,
dilated oesophaguspresents many of the radiological appearances ofa
mediastinal tumour. When the dilatation is
greatest in the aircontaining upper third of theorgan, a
diagnosis of lung cyst, lung abscess, oreven pneumothorax may be
made.
In one instance the patient was admitted to amedical ward with a
diagnosis of acute rheu-matoid arthritis. Examination suggested
acutepulmonary osteoarthropathy and further investi-gation
confirmed the presence of achalasia of thecardia. The association
of pulmonary osteo-arthropathy and oesophageal disease is
nowrecognized. In this case the retention oesophagitiswas so severe
that all mouth feeding was stoppedand a preliminary gastrostomy
performed: within48 hours all pain and swelling had disappearedfrom
the joints. One month later a Heller operationwas performed and the
gastrostomy allowed toclose.
Investigation is carried out by means of radio-logical
examination and oesophagoscopy. Theradiological appearances are
well recognized,especially the smooth, conical,
constrictionconfined to the cardia that characteristicallyrelaxes
after the inhalation of octyl nitrite. Theprotean appearances
presented by the dilatedoesophagus on plain radiological
examinationmimic all forms of mediastinal pathology. Inno other
form of oesophageal obstruction is acomparable degree of
oesophageal dilatation seen.
CEsophagoscopic examination is unsatisfactoryowing to the
difficulty of clearing the gullet of itsretained debris. The
examination is safer whenperformed in the sitting position under
localanesthesia; induction of general anaesthesia maylead to sudden
flooding of. the air passages withoesophageal contents. The main
object of thisexamination is to inspect the mucosa and determinethe
severity of the retention oesophagitis. Acareful inspection is
carried out for any signs ofearly malignancy. It is rare for any
convincingview to be obtained of the cardia and the exclusionof a
malignant or benign stricture at the cardiamay be
impossible.Relationship to Carcinoma of the (Esophagus
In the author's series of 94 cases of achalasiaof the cardia
there were eight cases of cesophagealcarcinoma. In four cases the
patients presentedwith severe obstruction due to advanced
carcino-mata; radiological examination revealed theunderlying
achalasia and megaoesophagus. Theremaining four patients had
previously beentreated for achalasia and returned with
recurrentobstruction due to malignant strictures 15 monthsto five
years following the Heller operation. In alleight cases the growths
were squamous cell intype, were situated in the mid-third of the
gullet,and had reached an advanced stage before obstruc-tive
symptoms occurred owing to the previous
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BELSEY: Functional Disease of the (Esophagus
FIG. 9.-Achalasia of the card'a complicated by anadvanced
carcinoma of the middle third of theoesophagus.
dilatation of the oesophagus (Fig. 9). In one casemultiple
carcinomata were present. Inaseriesofover500 cases of hiatus hernia
complicated by refluxcesophagitis observed and treated by the
author,there was no instance of a squamous cell
carcinomacomplicating the oesophagitis although severalco-existing
adenocarcinomata of the cardia wereencountered. This evidence
suggests that theretention cesophagitis complicating achalasia is
apre-malignant condition involving a high risk ofmalignant
degeneration; that the reflux cesophag-itis found in association
with a hiatus hernia isnot a pre-malignant condition. Of great
interestare the four patients who developed malignantstrictures
subsequent to Heller operations, andin one case five years later.
It is probable inretrospect that malignant degeneration had
alreadycommenced at the time of the original operation.As already
stated it is notoriously difficult toconduct a thorough examination
of the wholecesophageal mucosa, and when grossly inflamedand
obscured by rotting food debris and barium-an early carcinoma can
easily escape detection.In four of the cases determined but
ultimatelyfutile attempts were made to resect and reconstruct
the gullet, but in no instance was the growthoperable by normal
standards. It is logical toassume that the sooner steps are taken
to relieve theobstruction and oesophagitis in achalasia, the
lessthe risk of subsequent malignant degeneration.
TreatmentPre-operative care is important. If gross
oesophagitis is present a course of octyl nitriteinhalations
following low residue meals willdrain the osophagus from below. It
may benecessary to pursue this regimen for three tofour weeks
before it is safe to proceed withsurgical treatment. In two cases
in the author'sseries it was necessary to perform
temporarygastrostomies and stop all mouth feeding tobring the
inflammation under control. CEsopha-geal washouts are dangerous
owing to the risk ofdrowning the patient.An intensive course of
physiotherapy to improve
the pulmonary complications is usually called for.The patient's
nutritional state may be severelydepleted from chronic starvation;
this againmust be corrected and blood transfusion may
benecessary.Numerous operations have been described for
the relief of this condition. Repeated dilatationsenjoyed a
short vogue of popularity which was notjustified by the results,
and has now beenlargely abandoned by even its most
ferventadvocates. Various forms of oesophago-gastro-stomy have been
performed, to be followed in ahigh percentage of cases by
disastrous gastro-oesophageal reflux and ulceration. An
extra-mucous myotomy (Heller operation) dividing allthe circular
muscle fibres over the lower two tothree inches of esophagus is the
most satisfactoryoperation available at the present time.
Theoperation is best performed through the chestas only an
inadequate myotomy incision is possiblethrough the abdominal
approach. Franklin hasrightly said that it is an easy operation to
performbut a difficult operation to perform well. In itsoriginal
form the operation was not entirelysuccessful, the occasional poor
results being dueto the development of fibrous strictures
secondaryto gastro-cesophageal reflux. It has not beengenerally
recognized that any surgical inter-ference with the region of the
cardia may weakenthe already precarious valvular mechanism,
andprecipitate the development of a hiatus herniaor patulous cardia
and its sequelae. The authorhas in recent years employed a
modification ofthe Heller procedure. Recognizing the risk of
ahiatus hernia developing, the cardia is boldlyfreed from its
attachments and following themyotomy a formal hernia repair is
carried out
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298 ~~POSTGRADUATE MEDICAL JOURNAL My16
~·:il:-:..........i::.."Z:..
;r~~~~~~:...:.:.':··:.::·:...."~ii:iiiiii:.:iii...~¥i~!!i~~ii~iii...:.·.'.'
'.:··....:. :..':::.:-
i¥~".i%:::'.:".."'.islli'..". " rr:.¥i~
FIG. io.-(a) Mega-cesophagus complicating achalasia of the
cardia. (b) Nineyears following modified Heller myotomy; the
cesophageal dilatationhas disappeared.
by creating an acute angle of entry at the cardia,restoring an
intra-abdominal segment of cesopha-gus, and approximating the two
halves of theright crus behind the hiatus to form a buttressagainst
which the intra-abdominal segment ofoesophagus can be compressed by
the abdominalpressure. In a personal series of go cases
treatedsurgically, in the first 56 a formal Heller operationwas
carried out with satisfactory initial results,but in six cases, or
11%, fibrous strictures subse-quently developed of sufficient
severity to needesophago-gastric resection and reconstruction(Fig.
Io). In the last 34 cases the modified operationhas been performed
and as yet there has been noinstance of stricture formation or
subsequentnecessity for further surgery. There was
onepost-operative death in this series, from uraemiadue to
co-existing chronic nephritis.The surgical relief of functional
cesophageal
obstruction is justified by the gratitude of thepatient, by the
satisfactory long-term results, and
by the relative safety of the surgical proceduresindicated.
SummaryI. A series of 132 cases of functional disorders
of the oesophagus has been described. Of these 120required
surgical treatment for relief of dysphagia,or the pulmonary
complications of oesophagealobstruction.
2. No operation for pharyngeal diverticulum iscomplete unless
the underlying spasm of theupper sphincter is relieved.
3. Pulsion diverticula of the lower esophagusrarely need
surgical treatment; the underlyingfunctional obstruction frequently
does.
4. Achalasia of the cardia is a pre-malignantcondition.
5. The Heller operation must be accompaniedby the reconstruction
of a functioning valvularmechanism at the cardia to prevent
subsequentgastro-cesophageal reflux and fibrous stenosis.
REFERENCESFRANKLIN, R. H.: Personal communication.HURST, SIR A.
(1943): Respiratory Complications of Achalasia of the Cardia with
Mega-CEsophagus, Guy's Hosp. Rep.,
92, 68.NEGUS, V. E. (1950): Pharyngeal Diverticula: Observations
on Their Evolution and Treatment, Brit. J. Surg., 38, 129.
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