compression of the oesophagus by aorta1 - thorax · thorax (1969), 24, 32. compression of the...

Thorax (1969), 24, 32.

Compression of the oesophagus by the aorta1I. K. R. McMILLAN AND I. HYDE

From the Wessex Cardiac and Thoracic Centre, Southampton Chest Hospital

Compression of the lower dorsal oesophagus by the aorta in elderly women sufficient to causedysphagia has not received the attention it deserves. It is not a rare condition. The reasons forits neglect are probably two-fold: (1) the degree of dysphagia is often only slight or moderate,and (2) misdiagnosis. Occasionally, the dysphagia is serious and a threat to life. The clinicaland radiological features are here described and a rational operative treatment for the severecases is proposed. Such operative intervention does not seem to have been described previously.

With advancing age the aorta dilates, elongates,and becomes tortuous; some degree of cardiacenlargement is common, particularly involving theleft ventricle; the dorsal spine tends to becomekyphotic. The oesophagus, being in such closerelationship to the aorta and left ventricle, isaffected to a greater or lesser degree by all thesechanges. The resultant appearance as seen on abarium swallow is well known. That these changesof ageing can lead to dysphagia is less well known,and in fact most books and papers on this topiceither deny such an association or at most statethat it is rare and unimportant. Much greaterimportance is usually attached to the intrinsicchanges in the oesophagus due to ageing as acause of dysphagia, namely, loss of muscle tone,reduced peristaltic activity, and a failure of thelower end to relax.Mucklow and Smith (1954), in a paper describ-

ing the variable radiological appearances producedin the barium swallow by the aorta, noted twopatients who had dysphagia. One of these wassubjected to a Heller's operation and the finalclinical diagnosis was 'atypical achalasia', a diag-nosis with which the authors disagreed.

Keates and Magidson (1955) described sevencases of dysphagia which they believed were dueto aortic compression, in some cases supplementedby enlargement of the left ventricle which effec-tively squeezed the lower oesophagus betweenthese two structures. Three of these were oeso-phagoscoped, one showing such alarming pressurefrom the aorta that no attempt was made to reachthe cardia. They described the different types ofdeflection produced by a high or low cross-over of

'Based on a paper read at the Southampton meeting of the Societyof Thoracic Surgeons of Great Britain and Ireland, September 1967

the aorta behind the oesophagus and named themthe 'reversed C' and 'reversed S' forms. They alsonoted that the crossing of the aorta behind thelower end of the oesophagus pushed the latterforwards and that the barium seemed to cascadeover this hump. There was no operative confirma-tion in any of these cases.

It is our contention that dysphagia from thiscause is not uncommon and, whilst usually mild,it is occasionally very severe. It can be improvedby treatment.The patients are all old women, a point noted

by Keates and Magidson (1955). Kyphosis, tor-tuosity of the aorta, cardiac enlargement, and ahistory of heart failure are common. In a typicalcase the oesophagus is dilated and its lower endtapers either gradually or suddenly to a point justabove the diaphragm. The aorta passing behind itdeflects the oesophagus forwards like a cascadewhich is best seen with the patient in the leftanterior oblique position. There will be delayedemptying but if the patient continues to drink thebarium a sufficient head of pressure will be builtup to force it through at an increased rate. Oncessation of drinking the pressure falls and empty-ing stops. A significant residue may remain in theoeosphagus for a long time. The examination isbest performed with the patient erect since in oldpeople some dilatation and delay in the supineposition is commonly the result of the intrinsicoesophageal changes of ageing. If these changesare present during gravity-assisted swallowing thencompression can be diagnosed with greater cer-tainty. Many old people show oesophageal deflec-tion on barium swallow, but without signs ofobstruction and consequently they have no symp-toms. In the production of obstruction and thesymptoms of dysphagia the Jcute angulation which

32

copyright. on D

ecember 11, 2020 by guest. P

rotected byhttp://thorax.bm

j.com/

Thorax: first published as 10.1136/thx.24.1.32 on 1 January 1969. D

ownloaded from

http://thorax.bmj.com/

Compression of the oesophagus by the aorta

the oesophagus is forced to take in order to reachthe hiatus is the important feature. The encroach-ment on the oesophagus is from behind by theaorta and from in front by the anterior rim of thehiatus. The kyphosis is probably important for tworeasons-it allows the oesophagus to fall back-wards into the concavity of the curve, and thesecondary lordosis coming out of the kyphosisforces the aorta and oesophagus forwards. Thenett effect of these two forces is to increase theangulation or tightness of the curvature of theterminal portion of the oesophagus. The fact thatthis disorder of the oesophagus has been foundonly in women may be due to their greater lia-bility to develop dorsal kyphosis. There is noobvious reason why it should be exclusive towomen.

ILLUSTRATIVE CASES

CASE 1 A woman aged 85 had had recent difficultyin swallowing with fluid regurgitation and a sensationof sub-sternal sticking. A barium swallow showed theoesophagus to be dilated (Figs 1 and 2) and there wasmoderate hold-up. Slight reflux was elicited but nohiatus hernia. The oesophagus tapered suddenly to apoint of obstruction just above the diaphragm.Oesophagoscopy was only accomplished to 35 cm.because of the kyphosis but a bougie passed througheasily. Minimal oesophagitis was present, but therewas no growth and the obstruction did not feel like

FIG. 1. Case 1. Postero-anterior view. Pointof obstruction above the diaphragm.

a stricture. There was no visible reflux but the cardiawas not seen. The obstruction was dilated up to 29F.

In view of her age no further treatment was recom-mended and one month later swallowing was muchimproved. After four months the only complaint wasof minimal dysphagia and the patient was discharged.

CASE 2 A woman aged 83 experienced attacks ofdysphagia which frightened her but between attacksshe could swallow well. In addition she suffered fromchronic heart failure.A barium swallow showed a dilated oesophagus

(Fig. 3) and there was moderately severe hold-upwhich required a head of pressure to overcome theobstruction. Within the tight forward curvature wasthe calcified aorta which was also producing animpression on the gastric fundus (Fig. 4). There wasno hiatus hernia or reflux.No further investigation was undertaken on this

frail patient. In the course of the next 12 monthsshe was seen periodically by her doctor who reportedthat she continued to have intermittent dysphagiawith sticking but the attacks were less alarming.

CASE 3 A woman aged 71 had consulted her doctorbecause of the recent onset of dysphagia. She washypertensive (B.P. 250/105 mm. Hg) and had beentreated for many years for mild heart failure. Thebarium swallow had been reported as normal but infact it showed oesophageal deflection by the aortaabove the diaphragm and a moderate degree ofproximal dilatation. Her doctor requested a surgicalopinion to exclude an organic lesion.

FIG. 2. Case 1. Left anterior oblique view(L.A.0.). Extreme narrowing by compres-sion from behind.

33

copyright. on D



j.com/


ownloaded from


1. K. R. McMillan and 1. Hyde

heart failure were the only other recommendationsfor her future management.

CASE 4 A woman aged 78 was admitted to hospitalas an acute abdominal emergency. She complained ofepigastric pain radiating upwards into the chest andjaw and had vomited bright red blood several times.There was no relevant previous history.A barium swallow was given and the barium mixed

with a resting residue of mucus and food in the oeso-phagus, which was slightly dilated (Fig. 5). A forwarddeflection was shown at its lower end and also astriking impression over a long segment at a higherlevel. There was no hiatus hernia or'reflux.

FIG. 3. Case 2. R.A.O. Obstruction above the diaphragm.

FIG. 4. Case 2. L.A.O. Characteristic forward bowing.

At oesophagoscopy the cardia was at 38 cm., andminimal oesophagitis and minimal reflux were seen.The angle of entry was fair. There was no growth.A bougie was passed without difficulty and theobstruction dilated up to 32F. Operation was to beconsidered if no improvement resulted from the oeso-phagoscopy. However, two months later all dysphagiahad disappeared. Treatment of the hypertension and

FIG. 5. Case 4. L.A.O. Food and secretions in oesophagus.Compression by the aorta on the gastric fundus and alsoan elongated impression on the lower 7 cm. of oesophagus.

At oesophagoscopy there was an intense oeso-phagitis and an obstruction at 35 cm. but the lattercould relax and it was therefore presumed to bemuscular rather than fibrotic. There was no growth.Dilatation up to 29F. was achieved.A repeat of the barium swallow two days later

showed a striking improvement and an appearancewhich would pass as normal (Fig. 6).One can only conclude that some of these patients

are in a delicately balanced state which is readilytilted towards further obstruction by a variety ofevents. A cycle of obstruction->delay--oesophagitis->further obstruction is then initiated which has to bebroken before improvement can take place.

CASE 5 A woman aged 65 complained of increasingdysphagia together with pains in the epigastrium,behind the sternum, and in the back. She had lost

34

copyright. on D



j.com/


ownloaded from



Oesophagoscopy showed much fluid content andan oesophagitis was noted. The oesophagoscope waspassed to 40 cm. and the angle of entry into thestomach was normal.At operation the oesophagus was found to be com-

pressed between the left ventricle and the aorta, thelatter being twice normal size. Slight muscle thicken-

.... ing in the oesophagus was noted. The oesophagus wastransposed forwards 1 in. (2-5 cm.) and a Heller'smuscle split was performed.

Swallowing was improved and a repeat bariumexamination two months later confirmed this; thelumen at the hiatus had been widened (marked bythe clips in Fig. 8) but the deflection persisted and thiswas still causing a little hold-up. There was a normal

FIG. 6. Case 4. After bouginage a normal appearanceexcept for a somewhat anterior displacement of the cardia.

14 lb. (6-4 kg.) in weight. One year previously she hadbeen investigated because of dysphagia but appar-ently nothing was found. B.P. 140/84 mm. Hg.A barium swallow showed a dilated oesophagus

with delayed emptying and a gradual tapering of itslower end to a point above the diaphragm. There wasa characteristic deflection at its lower end (Fig. 7). Theaorta was very dilated and elongated

FIG. 8. Case 5. After operation. Oesophageal hiatusmarked by clips. Gas in stomach. Good width of lumen.Pronounced aortic impression 7 cm. above the cardia.Dilatation persists but the oesophagus has emptied ofbariwn.

gas bubble in the fundus. On lying down some incom-petence of the cardia was found.The complaints of pain were unchanged and this

may be explained by the unusual dilatation of theaorta.

CASE 6 A woman aged 75 complained of abdominalpain and vomiting. A diagnosis of cardiac ischaemiahad been made on the basis of atrial fibrillation,heart failure, and the E.C.G. changes. However, sixmonths later the pains and vomiting were no betterand she had lost 21 lb. (9-5 kg.) in weight She stated

FIG. 7 Case 5 Characteristic deflection and compression, that 'life was miserable'.

35

copyright. on D



j.com/


ownloaded from


I. K. R. McMillan and I. Hyde

FIG. 9. Case 6. Persistent obstruction of sinister appear-ance.

A barium swallow showed moderate dilatation ofthe oesophagus with hold-up at a persistent obstruc-tion thought to be neoplastic (Fig. 9). There was nogas bubble in the stomach. No reflux or hiatus herniawas found.At oesophagoscopy there was no oesophagitis or

growth and the obstruction which was found at 35cm. seemed to be due to extrinsic compression ratherthan a stricture. It was dilated to 32F.There was no improvement and one week later she

was totally obstructed. A repeat oesophagoscopyshowed an intense oesophagitis and the obstructionwas dilated with difficulty. A biopsy showed notumour.At operation a thoraco-abdominal approach was

made in the belief that this was a neoplasm of thegastric fundus. There was no neoplasm and internalexploration through a gastrotomy revealed no evidenceof a stricture of the oesophagus. The normal oeso-phagus was being compressed by the aorta and leftventricle. It was transposed forwards and laterally 1in. (2 5 cm.), the crura being closed behind and theoesophagus fixed to the tendinous diaphragm bycircumferential stitches.A repeat barium swallow showed the lumen at the

lower end to be of good calibre and there was nohold-up. The deflection was still present.One year later the most that she could be persuaded

to admit to was an occasional sensation of stickingat the supra-sternal notch. She had noticed a reduc-tion in sputum volume. At this time another bariumswallow (Fig. 10) showed very rapid emptying of theoesophagus. It was not possible to produce any 'build-up' of barium no matter how quickly she swallowed.Within 1 second of the completion of such rapidswallowing the oesophagus was quite empty, whichis unusual even in normal old people. There was noreflux or hiatus hernia.CASE 7 A woman aged 63 had a very severe kyphosisdue to old tuberculous disease of the dorsal spineand, in addition, severe rheumatoid arthritis of both

FIG. 10. Case 6. After operation. Good width of lunmenbut deflection persists.

.e..................~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.........

FIG. 11. Case 7. Gradual taper. Small gas bubble instomach.

hips. She could only hobble about with the help ofsticks. For three years she had experienced progres-sive dysphagia. A barium swallow showed the oeso-phagus to be dilated and tapered gradually to a point.There was hold-up of the barium. The stomach con-tained a gas bubble (Fig. 11).No further investigation was attempted at this time

but four months later her condition was deterioratingseriously. She was anaemic and had lost weight.

36

copyright. on D



j.com/


ownloaded from



Epigastric and retro-sternal pain was complained ofand food stuck unless it was finely chewed. Evenrapid drinking produced sticking.Oesophagoscopy was accomplished to 25 cm. only

and a tube could not be passed into the stomach. Atoperation the oesophagus was normal but tightlyclamped between the aorta and left ventricle. It wastransposed forwards and laterally 1 in. (2-5 cm.).

Post-operatively she developed dilatation of thestomach and duodenum (the so-called duodeno-mesenteric ileus) which responded to conservativemeasures. There was no further dysphagia and arepeat barium swallow showed that there was nodilatation or delay (Fig. 12). There was a good lumen

FIG. 12. Case 7. After operation. Dilatation no longerpresent. Good lumen width. Larger gas bubble in stomach.

width at the lower end but some deflection higher upwas still present, as is to be expected. The extremekyphosis no doubt explains the earlier onset of symp-toms in this case. Seven months later there was nodysphagia but free eructation and some nausea werepresent. The patient was well satisfied with the result.

DISCUSSION

The first four cases described are examples ofaortic compression but proof is not available. Inthe last two years we have seen 10 cases whichsatisfy for us the criteria for this diagnosis. Theycome from a general radiological practice as wellas from a thoracic surgical unit, and this explainsthe high incidence of the severe types. We believethere are many other cases in our area of whichwe are unaware.The last three cases were operated on and proof

of severe compression was obtained. This com-pression was the most important element in theproduction of their dysphagia but it is conceded

that in case S the muscle thickening at the lowerend of the oesophagus may have be_n con-tributory. However, this case was treated manyyears ago (not included in the 10 mentionedabove) and our present attitude would be to omitthe muscle split as being irrelevant. It is alsoprobable that the pain which was such a featureof this case was due to the aneurysmal enlarge-ment of the aorta.From the radiological point of view there are

four parts to this diagnosis:(1) Oesophageal deflection of characteristic type.(2) Significant hold-up. By this is meant more

than the usual small residue which is commonlyfound in old age.

(3) Dilatation-but again with the understand-ing that some dilatation is not uncommon in oldage. However, this 'normal' dilatation of old ageis transient.

(4) A persistently narrowed segment.Difficulties in diagnosis are likely to arise if

one or more of these features is absent or incon-spicuous. For instance, if the tight forward curva-ture of the lower end of the oesophagus is notapparent then a mistaken diagnosis of achalasiais likely to be made. Points against this would bethe presence of a gas bubble in the stomach,absence of response to octyl nitrite, and the differ-ent behaviour to a 'head of pressure'. The leftanterior oblique projection is ithe best position toshow the forward bowing of the lower end of theoesophagus. A peptic stricture may be simulated,but in our cases there was no hiatus hernia andonly one showed slight gastro-oesophageal reflux.A neoplastic stricture, particularly from a carci-noma arising in the gastric fundus or from meta-stases encircling the cardia, is another difficultproblem in differentiation, especially as thenarrowed segment may not be accessible to theoesophagoscope because of the kyphosis and thenexploration may be necessary to make sure, as incase 6.

Oesophagoscopy is an essential part of theinvestigation in order to eliminate any otherpathological lesion but it may not be diagnostic.It may show appearances suspicious of extrinsiccompression and this, together with the radio-logical features, makes the diagnosis a likely one.In mild cases it seems to have therapeutic valuesince, to our surprise, three patients improvedafter this alone.

Antero-lateral transposition of the oesophagusis the surgical method of choice as it is simpleto do and at operation the anatomical arrange-ment causing the dysphagia is easily identified.

37

copyright. on D



j.com/


ownloaded from


1. K. R. McMillan and 1. Hyde

After a successful operation the deflection of theoesophagus by the aorta can be expected to per-sist and there may indeed be some residual dilata-tion but the crucial tests are the transient nature ofthe dilatation, the absence of hold-up, and rapidemptying.The following classification indicates the range

of these cases:(1) Oesophageal deflection only, an incidental

finding without symptoms.(2) Mild dysphagia. Dilatation and hold-up will

be present but the symptoms are so inconspicuousthat often no further action is taken. The bariumswallow may have excluded other causes withreasonable certainty and further investigation maynsot be considered justified because of age orinfirmity. The patient is likely to suffer inter-mittent, mild symptoms for the rest of her life.

(3) Moderately severe dysphagia. Oesophago-scopy and/or bouginage will usually cause someimprovement which may last the rest of thepatient's life, but it may have to be repeated, inwhich case the patient is entering the fourthgroup.

(4) Severe dysphagia with a deteriorating clinicalstate. Bouginage may not produce any improve-ment or any such improvement may be short-lived.The patient may require operation.Any procedure which frees the oesophagus

from the hiatus may suffice, and a Heller's opera-tion performed in the mistaken belief that achal-asia is the cause of the symptoms may improvethe condition. However, a more rational approachis to move the oesophagus forwards and laterallyaway from the obstruction. This will give con-siderable if not complete relief. In transposing theoesophagus care must be taken to maintain itscorrect anatomical position so that the cardia is1 in. (2-5 cm.) below the diaphragm. The endresult should be an oesophagus with no obstruc-tion, no hiatus hernia, and no reflux.

REFERENCES

Keates, P. G., and Magidson, 0. (1955). Dysphagia associated withsclerosis of the aorta. Brit. J. Radiol., 28, 184.

Mucklow, E. H., and Smith, 0. E. (1954). Dysphagia and unusualradiographic appearances associated with the variable relation-ships of the aorta and lower oesophagus. J. Fac. Radiol. (Lond.),6, 88.

38

copyright. on D



j.com/


ownloaded from


compression of the oesophagus by aorta1 - thorax · thorax (1969), 24, 32. compression of the...

Documents