Transpleural Cardioplasty in Achalasia: Operation Results and Sequelae

The clinical syndrome characterized by dysphagia, retrosternal or epigastric pain, and, in advanced stages, by regurgitation of undigested food and total obstruction of the oesophagus, has long been known and has been called by many different names.The Englishman, Thomas Willis, gave a detailed description in 1672, and after 1882, when v. Mikulicz, who believed it to be caused by a spasm in the region of the cardia, published his studies on the subject the syndrome was known as "cardio- spasm"; this name is still in current use in many countries.When later investigations disproved the occurrence of a spasm in the cardiac region Hurst (1914) introduced the name " achalasia," or lack of relaxation of the cardiac sphincter.But in the light of our experience and knowledge to-day it seems that the condition is due to a combination of factors and not solely to failure of relaxation, so that Hurst's suggestion is no longer satisfactory.Imbalance in the nerve supply to the cardiac sphincter may be responsible for the onset; if so, the sphincter does not respond by relaxing to waves of peristalsis from the oesophagus but remains closed and thereby arrests the descent of the food to the stomach until the cardiac orifice has been opened by dilatation or surgical intervention or until later on it spontaneously relaxes.Our knowledge of the aetiology is still obscure, but causal factors do not seem to be uniform.Some authors ascribe the disease to a disorder in Auerbach's plexus (Rake, 1927; Cameron, 1927; Mosher and McGregor, 1928) or to lesions of the central nervous system.Others envisage the possibility of vagotonia (Held and Gross, 1916), degenerative changes in the vagus (Kraus, 1902;Heyrovsky, 1913;Pollitzer, 1913) or a sympathetic nerve derangement (Carlson and Luckhardt, 1921 ; Kurd, 1929; Knight, 1934, and others).Sauerbruch and v. Haecker (1906) suggested that the diaphragm was concerned, and Jackson, who shared this view, proposed the name of " phrenospasm " for the syndrome.*Several surgeons in Great Britain have had isolated cases in which vagotomy has been followed by the typicar radiological and clinical manifes:ations of achalasia.These symptoms have been of temporary duration.-EmToR.