Circular Myotomy Research Articles

Circular myotomy and Belsey repair for acquired shortening of the oesophagus.

Fourteen patients with shortening of the oesophagus due to chronic reflux oesophagitis have been treated by a combination of an oesophageal lengthening procedure with a standard anti-reflux repair. Their ages ranged from 18 to 78 years and eight were male. Thirteen patients had a reflux stricture (with additional penetrating ulcer in six) and one had a columnar-lined oesophagus. A complete circular myotomy was performed just below the level of the aortic arch, in combination with a Belsey Mark IV anti-reflux repair. There were no deaths post-operatively but one patient required re-operation for haemorrhage and one underwent oesophageal dilatation before discharge. All patients have now been followed up for over 5 years. Nine patients have required no further treatment for their oesophageal problems, two required two early dilatations each, two required multiple dilatations and one required oesophageal resection for stricture. We suggest that this combination merits further evaluation in the management of patients with short oesophagus due to reflux.

Primary repair without routine gastrostomy is the treatment of choice for neonates with esophageal atresia and tracheoesophageal fistula.

Gastrostomy and staged repair are techniques frequently recommended for the management of esophageal atresia with distal tracheoesophageal fistula (EA-TEF), especially for those infants at high risk. We describe 42 consecutive patients with EA-TEF treated during the past 8 years. Staged repair and preliminary gastrostomy were not routinely employed. Fifteen infants were considered to be at high risk (Waterston class C). Surgical treatment via an extrapleural approach consisted of fistula division and primary single-layer end-to-end esophageal anastomosis. Four patients required proximal esophageal circular myotomy. Four patients early in the series received a gastrostomy at or before definitive repair for various life-threatening indications. One patient had fistula division only and died before esophageal anastomosis was possible. Two neonates died before repair and another died after repair. The deaths in this series of patients were unrelated to EA-TEF. One patient developed a clinically significant anastomotic leak. Four patients required multiple dilatations for anastomotic stricture. Fundoplication was necessary in 3 patients with symptomatic gastroesophageal reflux. Our data demonstrate that excellent overall survival (90%) with low morbidity (15%) can be achieved using primary repair without preliminary gastrostomy in most neonates with EA-TEF. We believe that mortality in high-risk patients with EA-TEF is due to associated life-threatening anomalies.

An improved technique for in situ esophageal myotomy and proximal pouch mobilization in patients with esophageal atresia

The use of a modified endotracheal tube in the mobilization of the upper pouch in patients with esophageal atresia is described. While aiding mobilization in all patients the tube was particularly helpful in the performance of circular myotomy where this was necessary. The tube and the operative technique are described.

Evaluation of the intrinsic innervation of the internal anal sphincter using electrical stimulation.

Stimulation of the rectal mucosa with a bipolar electrode leads to relaxation of the internal anal sphincter. Intraoperative studies in two subjects showed that transmission of the impulse was independent of extrinsic nerves and was interrupted by circular myotomy. Characteristics of the reflex were studied in 11 healthy women and 19 women with severe idiopathic constipation. One control subject and two patients did not tolerate the test. In the remainder the stimulus caused a clearly defined fall in internal sphincter pressure. The mean resting maximum anal canal pressure before stimulation was the same in both groups (90 (10) v 104 (7) cm H2O, p = 0.3, controls v patients). The threshold stimulus for relaxation (12 (2) v 14 (1) mamps, p = 0.5), the maximum percent fall in resting pressure (43 (7) v 46 (4)%, p = 0.7) and the lowest absolute resting pressure produced by stimulation (48 (13) v 49 (6) cm H2O, p = 0.9) were the same in both groups. The stimulus required to achieve maximum relaxation was significantly higher in the patient group (23 (3) v 32 (2) mamps, p = 0.012) suggesting abnormal intrinsic innervation of the sphincter in these patients. Electrical stimulation should not replace balloon distension for routine testing of the rectoanal reflex but it may be useful in quantitative studies.

Management of a post-Livaditis-procedure oesophageal diverticulum

The findings and management in a male patient who developed a symptomatic oesophageal diverticulum 6 years after a circular myotomy was used to facilitate oesophageal anastomosis during repair of his oesophageal atresia are described.

Circular myotomy for esophageal stricture

In this paper circular myotomy is described in the treatment of localized esophageal stricture, following accidental swallowing of silver nitrate. The stricture was 4 cm long, extending from the oropharynx to the thoracic inlet. After resection, establishment of esophageal continuity was only possible after performing circular esophageal myotomy. This procedure can be attempted before embarking on esophageal replacement operations.

Esophageal manometrical assessment after esophageal circular myotomy for wide-gap esophageal atresia.

We treated 3 children with wide-gap esophageal atresia by a circular myotomy of Livaditis technique, after which no postoperative complaints, such as heartburn, vomiting or dysphagia, were seen. Esophageal manometry, performed to evaluate the postoperative esophageal motor function revealed; (1) that lower esophageal sphincter pressure (LESP) increased gradually with time, (2) esophageal contraction waves (ECW) were evident at the site of the circular myotomy with swallowing, though these contractions were simultaneous; and (3) relaxation of the LES with swallowing was evident. These findings, as determined by the esophageal manometrical assessments, indicate that there is no difference between the postoperative esophageal function after either repair with a circular myotomy or primary anastomosis for esophageal atresia.

High proximal pouch esophageal atresia with vertebral, rib, and sternal anomalies: An additional component to the VATER association

The base of the proximal esophageal pouch in babies born with esophageal atresia varies in location from the low cervical region to the upper third of the mediastinum, but the relevance of this finding to the VATER association is not known. The initial radiographs and hospital records of 42 newborns with esophageal atresia and a distal tracheoesophageal fistula treated in the Newborn Special Care Unit of the Yale-New Haven Hospital between 1977 and 1986 were examined to (1) determine the location of the base of the upper esophageal pouch on its superimposed vertebral body; (2) identify coexisting VATER associated anomalies; and (3) detect the presence of vertebral, rib, or sternal anomalies. Ten of 11 babies with the upper esophageal pouch at the first thoracic vertebra or above had additional VATER defects including vertebral, rib, or sternal anomalies. These patients also required staged repair or circular myotomy for wide gap esophageal atresia and were at greater risk of anastomotic leak, stricture, or gastroesophageal reflux requiring fundoplication. High proximal pouch esophageal atresia accompanied by vertebral, rib, and sternal anomalies constitutes a heretofore unrecognized high risk group with the VATER association.

Esophageal atresia: A simple technical detail aiding the mobilization and circular myotomy of the proximal segment

A simple technical detail in placing the upper pouch holding suture to facilitate proximal segment mobilization in esophageal atresia is described. The suture is passed through both walls of the upper segment and the tip of the Foley catheter. If circular myotomy is needed, the Foley catheter balloon is inflated to fill the lumen of the upper pouch to facilitate dissection. This technique has been successfully used in 32 patients, eight with myotomy.

Transcervical myotomy for wide-gap esophageal atresia

A primary end-to-end anastomosis of the esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty.

Diverticulum formation after circular myotomy for esophageal atresia

Out of our last 70 cases of esophageal atresia, a circular myotomy of the upper pouch (Livaditis technique) was required in six patients to achieve an end-to-end anastomosis: all had a lower tracheoesophageal fistula. They were operated on between 15 and 96 hours after birth, without any preoperative attempt of elongation of the upper pouch. Follow-up ranged from 14 to 77 months. Three patients had an uneventful postoperative course and late outcome, despite a moderate ballooning at the myotomy site in one. Three babies developed a mild stricture which responded easily to a few dilatations. Asymptomatic ballooning at the myotomy site was observed in one baby; the other two developed a diverticulum responsible for acute respiratory distress in one case and severe dysphagia in the other. both required esophageal replacement. These observations call attention to the fact that patients treated by myotomy should be followed very carefully early and late, especially if an anastomotic stricture develops or in case of associated tracheomalacia.

An improved technique for circular myotomy in long-gap esophageal atresia

Circular myotomy has allowed the surgeon to establish esophageal continuity in early infancy in patients with long-gap esophageal atresia. This report describes the use of a #5 Fogarty balloon catheter, passed by the surgeon into the proximal esophagus to facilitate the myotomy. The catheter is passed through a pursestring suture placed at the tip of the proximal esophagus. The balloon is inflated to fill but not distend the lumen. The myotomy is performed approximately two cm proximal to the esophageal end and; upon its completion, it will provide 1 to 1.5 cm of additional length. The advantages of the surgeon placing the catheter into the esophagus include: complete control of the balloon size and position, and the ability to use the catheter to manipulate the proximal esophagus atraumatically.

Circular Esophageal Myotomy in the Rhesus Monkey: Anatomical and Physiological Effects

Thirty-one rhesus monkeys were divided into six groups: a control group of 4 monkeys in which resection of 33% of the thoracic esophagus with end-to-end anastomosis was performed with-out myotomy, and test groups of 4 to 6 monkeys each in which circular myotomy in the proximal segment, distal segment, or both was combined with a 25% or 33% resection. In the control group, 2 of 4 monkeys survived. In the test groups, myotomy reduced longitudinal tension by 20 to 58%. Among the survivors were 4 of 6 animals that had 25% resection with proximal myotomy, 3 of 5 having 25% resection with distal myotomy, and 3 of 4 having 25% resection with combined proximal and distal myotomy. However, 4 of 5 monkeys that had 33% resection plus proximal myotomy and all 5 having 33% resection plus distal myotomy died of anastomotic leaks or strictures. Cineesophagography in surviving monkeys showed no motility disturbance at the myotomy sites. Manometry in 5 monkeys showed no change in resting lower esophageal sphincter pressure from that measured preoperatively. Postmortem examination in long-term survivors showed no stricture or dilatation at the myotomy sites. It is concluded that circular myotomy in the rhesus monkey reduces longitudinal tension, but compromise of the esophageal blood supply limits the usefulness of the procedure in bridging long gaps in the esophagus. Myotomy did not result in any motility disturbance or late anatomical sequelae, and therefore is still a valid procedure to facilitate the repair of short defects.

Correction of esophageal atresia with distal tracheoesophageal fistula

Correction of the full spectrum of esophageal atresia with tracheoesophageal fistula (TEF) remains controversial. Circular myotomy and other lengthening procedures have shown promise to reduce tension when a relatively wide gap exists between esophageal segments; nevertheless a relatively high complication rate persists. We believe anastomotic tension is commonly found with repair of this anomaly. Therefore, the construction of the anastomosis will be a primary determinant of success. Twenty-four infants with TEF were admitted, 12 (50%) weighing 2.5 kg, nine (37%) 1.8 to 2.5 kg, and three (13%) 1.8 kg. All underwent gastrostomy and end-to-end single-layer anastomosis. Gaps of up to 4.5 cm were encountered, and in one case a cervical incision was necessary for mobilization of the upper pouch. For eight patients (33%) the gap was at least 2.5 cm and significant anastomotic tension was generated. For the series, there were no anastomotic leaks (all confirmed by barium swallow), reoperations, or surgical complications (there were two late, unrelated deaths). Prophylactic dilation was routinely performed 6 weeks and 3 months postoperatively. Subsequently, seven of the 24 (29%) required additional (one to five) dilatations but are now asymptomatic at least 2 years later. Follow-up for the entire series is 5 months to 5 years. Three infants (13%) required fundoplication for reflux without stricture and two infants (8%) an aortopexy. For successful esophageal anastomosis we consider the following technical points important: (1) no-touch technique to minimize tissue damage, (2) generous (5 to 7 mm) full-thickness suture depth, (3) fine (6/0) monofilament suture to reduce tissue reactivity, and (4) in cases of significant tension, the sutures are preplaced and used to provide traction to eliminate tension during tying. Tension is often unavoidable in TEF, yet a carefully constructed anastomosis will withstand this stress. This approach provides results at least as satisfactory as the reported experience with a variety of techniques.

The Effect and Indication of Circular Myotomy in Esophageal Atresia

The Effect and Indication of Circular Myotomy in Esophageal Atresia

Developments in the Care of Patients with Esophageal Atresia and Tracheoesophageal Fistula

Both the mortality and morbidity associated with esophageal atresia and tracheoesophageal fistula have improved over the years. The treatment of patients with long-gap esophageal atresia by circular myotomy to the upper pouch with or without preoperative stretching has improved the care of patients with this problem.

Wide gap esophageal atresia with inaccessible upper pouch

Circular myotomy of the proximal esophageal pouch has allowed end-to-end esophagoesophagostomy in infants with wide gap esophageal atresia. Occasionally, the proximal pouch ends so high in the thorax that the circular myotomy is technically impossible under conventional means. Exteriorization, mobilization, and myotomy of the proximal esophageal pouch via a separate cervical incision has allowed us to overcome this limitation of an inaccessible upper pouch and has permitted esophagoesophagostomy. This technique has been performed successfully in two infants with good results and no morbidity over a follow-up period of 1 1/2 to 3 1/2 years.

Circular myotomy and esophageal length and safe esophageal anastomosis: An experimental study

The indication for circular myotomy is often unclear at the time of esophageal atresia repair because the maximal permissible tension at the anastomosis and the precise effect of myotomy on esophageal length and anastomotic tension are not known. This study was undertaken to answer these questions. In piglets, 0 to 6.5-cm segments of thoracic esophagus were excised and approximation force was measured by dynamometers attached to traction sutures in each cut end of the esophagus prior to anastomosis. When approximation force was greater than 75 g. esophageal leaks occurred and increased fibrosis was noted at the anastomosis. Circular myotomy of the upper segment reduced the force necessary to approximate the ends of the esophagus after a 5- to 6-cm resection by about 50%, and double circular myotomy by as much as 75%. When the upper third of the esophagus of piglets and neonatal cadavers was stretched by the application of traction forces of 0 to 75 g. esophageal length increased by about 40%. Thereafter, length increase ws minimal. For any given traction force, each circular myotomy increased esophageal length by about 5 mm. These studies suggest that accurate measurement of approximation force would be useful at the time of esophageal atresia repair. On the basis of these data, circular myotomy(s) is indicated to elongate the esophagus and reduce anastomotic tension when a force greater than 75 g is needed to approximate the esophageal ends.

Long-term follow-up of circular myotomy for esophageal atresia

Between January 1976 and March 1979, esophageal atresia was successfully repaired in six infants with circular myotomy (Livaditis technique) and end-to-end anastomosis. Children were 1 day-6 mo in age and weighed 2.4 to 8.0 kg at the time of repair. Four children required one and two children required two circular myotomies in the proximal esophagus to bridge gaps between esophageal ends, which varied from 1.2-3.0 cm. Follow-up has been 1-4 yr (mean-3 yr). Operative complications included: opening of the mucosa at myotomy (2) and anastomotic leak (2). Subsequently, three children developed anastomotic stricture which required dilatation. Current x-rays show ballooning of the esophagus at the myotomy site during swallowing in all. However, the esophageal diameter at the myotomy site was never more than 2 cm greater than that of the distal esophagus. In the three children with anastomotic stricture, mucosal ballooning was not greater than in the others. During follow-up, weights have ranged from the 3rd to the 50th percentile for age. Swallowing has been good in 4, fair in 1 (dilatation still required), and poor in 1 (oropalatal deformities necessitate gastrostomy feedings). Circular myotomy offers a safe means of esophageal lengthening. Complications directly related to the myotomy are minimal (mucosal tear) and should be recognized at operation. Ballooning of the mucosa at the myotomy site is a common late finding but diverticulum formation has not occurred. Swallowing and esophageal motility are similar to other children who have had esophageal atresia repair.

The technique of myotomy in esophageal reconstruction: An experimental study

Circular myotomy has been shown to be a useful technique for approximating widely separated segments in esophageal atresia. We tested variations of this technique experimentally in dogs and found a significantly greater decrease in tension after double, spiral, and stepladder myotomies. Complications as measured by mortality and morbidity (leaks, strictures, and weight loss) were not found to differ statistically in the various groups, although there is a suggestion that the spiral myotomy group may have less postoperative problems.