Esophageal resection for achalasia: indications and results

Although esophagomyotomy is highly effective as the initial surgical treatment of most patients with achalasia, those with either recurrent symptoms after a previous esophagomyotomy or a megaesophagus do not respond as well to esophagomyotomy. Total thoracic esophagectomy was performed in 26 patients (average age, 49 years) with achalasia. Eighteen had a history of a previous esophagomyotomy, and 18 had a megaesophagus (esophageal diameter of 8 cm or larger). In 24 patients, a transhiatal esophagectomy without thoracotomy was the operative approach; 2 patients required a transthoracic esophagectomy because of intrathoracic adhesions from prior operations. The stomach was used as the esophageal substitute in all patients; it was positioned in the posterior mediastinum, and a cervical anastomosis was performed. Intraoperative blood loss averaged 765 mL. Major postoperative complications included mediastinal bleeding requiring thoracotomy (2), chylothorax (2), and anastomotic leak (1). There were no postoperative deaths. The average postoperative hospital stay was ten days. Follow-up is complete and ranges from 3 to 91 months (average duration, 30 months). All but 1 patient with severe psychiatric disease eat a regular, unrestricted diet without postprandial regurgitation. Early postoperative anastomotic dilation was required in 10 patients. Dumping syndrome has occurred in 5 patients. It is concluded that esophagectomy provides the most reliable treatment of esophageal obstruction, pulmonary complications, and potential late development of carcinoma in the patient with a megaesophagus of achalasia or a failed prior esophagomyotomy and that it is a far better option in these patients than esophagomyotomy, cardioplasty procedures, or limited esophageal resection.     

Esophagectomy for End Stage Achalasia

Esophageal myotomy is the standard primary therapy for achalasia. However, reports on long-term results of myotomy have suggested a deterioration of outcome over time with many patients presenting with end stage disease several years after esophagomyotomy. Eight patients who had previously undergone esophagomyotomy for achalasia presented with recurrent or worsening symptoms, and after preoperative evaluation, were treated by esophagectomy via laparotomy and right thoracotomy. The mean age at the time of myotomy was 52 years (range 18 to 62 years), and the mean time until esophagectomy was 12.5 years (range 2 to 18 years) after the initial myotomy. The median time until esophagectomy was performed after myotomy was 14 years. All patients in this series gained weight (mean, 23 pounds; range, 9 to 42 lbs) following esophagectomy, and none of the patients complained of dysphagia at follow-up or developed stricture. There were no major complications (including anastomotic leak) or deaths in this series. Five of the patients have been followed a mean of six years and remain well. Esophagectomy is a safe and appropriate treatment option in the setting of recurrent and end stage achalasia.     

Transhiatal esophagectomy

Between 1991-2001, 40 patients underwent esophagectomy without thoracotomy for: caustic esophageal stenosis (26 cases), cervical esophageal cancer (1), lower esophageal cancer (7), and acute post-caustic oesophagitis (2). Thirty-four patients underwent transhiatal esophagectomy, 3 patients had an esophagectomy by "stripping" and in 3 other patients a combination of stripping and transhiatal esophagectomy. Postoperative complications included: injuries of the laryngeal recurrent nerve (2), pulmonary complications (13), anastomotic leakage (5). Two patients died in the postoperative period one from a myocardial infarction and the other from an acute myocardial dilatation. Trans-hiatal esophagectomy can be considered as a viable alternative to transthoracic esophagectomy in the management of the benign and malignant diseases of the esophagus. Transhiatal esophagectomy is a safe method of resection because of its reported lower morbidity and mortality and similar survival rates compared to transthoracic esophagectomy.     

Laparoscopic Heller myotomy relieves dysphagia in achalasia when the esophagus is dilated

Background: It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia. Methods: On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0–6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication. Results: The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy. Conclusions: In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment. Received: 1 March 1999/Accepted: 21 June 1999     

Video-assisted surgical management of achalasia of the esophagus.

PURPOSE: Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches. PATIENTS: Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1). METHODS: In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically. RESULTS: Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia. CONCLUSION: At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.     

Management of huge epiphrenic esophageal diverticula

Epiphrenic diverticula occur in association with motor disorders of the distal esophagus, including achalasia and diffuse esophageal spasm. Four patients with huge symptomatic epiphrenic diverticula are presented to emphasize the need for complete radiographic and manometric studies of the esophagus to document this motor dysfunction prior to performing combined diverticulectomy and esophagomyotomy. Each patient had achalasia with symptoms extending from 4 to 25 years. Diverticulectomy and esophagomyotomy were performed in every patient. One patient had previously undergone diverticulectomy alone, with prompt recurrence of the lesion. During a follow-up period extending from 2 to 10 years, three patients were alive and well. One patient developed recurrent dysphagia due to reflux esophagitis and stricture requiring dilatation. It is essential that esophagomyotomy be part of the initial operative procedure. In selected patients, an antireflux procedure may also be indicated.     

The Outcome of Laparoscopic Heller Myotomy for Achalasia is Not Influenced by the Degree of Esophageal Dilatation

In the past, a Heller myotomy was considered to be ineffective in patients with achalasia and a markedly dilated or sigmoid-shaped esophagus. Esophagectomy was the standard treatment. The aims of this study were (a) to evaluate the results of laparoscopic Heller myotomy and Dor fundoplication in patients with achalasia and various degrees of esophageal dilatation; and (b) to assess the role of endoscopic dilatation in patients with postoperative dysphagia. One hundred and thirteen patients with esophageal achalasia were separated into four groups based on the maximal diameter of the esophageal lumen and the shape of the esophagus: group A, diameter <4.0 cm, 46 patients; group B, esophageal diameter 4.0–6.0 cm, 32 patients; group C, diameter >6.0 cm and straight axis, 23 patients; and group D, diameter >6.0 cm and sigmoid-shaped esophagus, 12 patients. All had a laparoscopic Heller myotomy and Dor fundoplication. The median length of follow-up was 45 months (range 7 months to 12.5 years). The postoperative recovery was similar among the four groups. Twenty-three patients (20%) had postoperative dilatations for dysphagia, and five patients (4%) required a second myotomy. Excellent or good results were obtained in 89% of group A and 91% of groups B, C, and D. None required an esophagectomy to maintain clinically adequate swallowing. These data show that (a) a laparoscopic Heller myotomy relieved dysphagia in most patients with achalasia, even when the esophagus was dilated; (b) about 20% of patients required additional treatment; (c) in the end, swallowing was good in 90%.     

Revisional Surgery after Heller Myotomy for Treatment of Achalasia: A Comparative Analysis Focusing on Operative Approach

Surgical myotomy is the gold standard in therapy for achalasia, but treatment failures occur and require revisional surgery. A MEDLINE search of peer-reviewed articles published in English from 1970 to December 2008 was performed using the following terms: esophageal achalasia, Heller myotomy, and revisional surgery. Thirty-three articles satisfied our inclusion criteria. A total of 12,727 patients, with mean age of 43.3?years (males 46% and females 50%), underwent Heller myotomy (open 94.8% and laparoscopic 5.2%). Revisional surgery was performed in 6.19%. Procedures performed included revision of the original myotomy or creation of a new myotomy with or without an antireflux procedure or esophagectomy. Reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (3.04%). Systematic review of the literature for revisional surgery following Heller myotomy revealed a 6.19% rate of reoperation with a low mortality rate.     

Esophagectomy: Definitive Treatment for Esophageal Neuromotor Dysfunction

Twenty-two patients with a history of between one and four (average of two) unsuccessful prior esophageal operations for neuromotor dysfunction were treated with esophageal resection and replacement. Eleven (50%) had recurrent reflux esophagitis in association with various disorders of motility: esophageal spasm in 4, achalasia in 3, scleroderma in 2, and esophageal atresia in 2. Eight (36%) had primary esophageal spasm and 3 (14%) had achalasia. Esophageal obstruction, regurgitation, and severe spasm were the most common manifestations of the inability to swallow normally. Transthoracic or transhiatal (blunt) esophagectomies were performed in 5 and 17 patients, respectively. The stomach, with a cervical esophagogastric anastomosis, was used for esophageal substitution in 15 patients. Six patients underwent a long-segment colonic interposition, and 1 patient with achalasia underwent a distal esophagectomy and short-segment colonic interposition. One patient undergoing transthoracic esophagectomy for achalasia died from unrecognized intraoperative bleeding into the opposite chest. There were no other operative deaths. Additional complications included transient hoarseness in 8 patients, chylothorax in 1, and anastomotic leak in 1. After an average follow-up of 25 months for the 21 surviving patients, ability to eat is regarded as good in 18 (85%), fair in 1 (5%), and poor in 2 (10%).In patients with incapacitating esophageal neuromotor disease, a more radical operative approach—esophagectomy—may be safer and more reliable than attempting another procedure and risking another failure. Esophagectomy ensures definitive elimination of the esophageal problem and as optimal an ability to eat as possible. Our experience suggests that the stomach, with a cervical esophagogastric anastomosis, offers a better functional esophageal substitute than does a colonic interposition.     

Esophageal achalasia: cardiomyotomy or pneumatic dilatation?]

Sixty-four patients with achalasia of the esophagus were surgically treated during the period 1973-1990. They were analyzed a late follow-up (mean = 78 months) by means of subjective and objective parameters. The Authors emphasize the efficiency of the diagnostic approach so that surgical treatment offers better results. The surgical technique of choice consists of an anterior esophagomyotomy (extending from 6 cm above the esophagogastric junction down to 1-2 cm below it) with the addition of an anterior Dor antireflux procedure through a laparotomy. The other therapeutic approach to achalasia is pneumatic dilatation of lower esophageal sphincter. A retrospective comparison of two different treatments is made through the analysis of the literature (medlars 1986-1990). Relief of dysphagia is reported in 92.78% of patients treated by myotomy and in 78.71% of those treated by forceful dilatation. The morbidity rate is greater after pneumatic dilatation (6% vs 5%) and the mortality rate is 1.1% after myotomy and 0.2% after dilatation. There are not rigorous criteria of choice between the two treatment methods but the Authors indicate that Heller's myotomy with an antireflux procedure achieve better and lasting results.     

Esophagectomy for complex benign esophageal disease

We evaluated the use of total thoracic esophagectomy and replacement with stomach in a group of 21 patients between 1976 and 1986 who had undergone multiple unsuccessful esophageal operations. All patients had between one and four unsuccessful operations for benign esophageal disorders. Sixteen patients had primary motor disorders: achalasia in nine and esophageal spasm in seven. Of these patients, 11 also had recurrent gastroesophageal reflux and peptic esophagitis. Complicated reflux disease characterized by severe esophagitis, stricture, and impaired peristalsis without primary motor disorder occurred in five patients. In one patient a functionally impaired long-segment colon interposition was removed and replaced with stomach. Total thoracic esophagectomy and cervical esophagogastric reconstruction was done in all patients. The transhiatal approach was chosen for resection in 16 patients and thoracotomy was used in the other five. There was one perioperative death (5%), from massive aspiration 4 days after transhiatal esophagectomy. Other complications included transient anastomotic leak (three patients), tracheoesophageal fistula (one), recurrent nerve palsy (one), and transient hoarseness (two). Follow-up is complete between 1 and 10 years and reveals the following functional results: 12 patients good to excellent, seven fair, one poor. In this patient group in which multiple prior procedures have failed to improve severe incapacitating symptoms, we believe further attempts at hiatal reconstruction are unlikely to succeed. For this circumstance, we recommend total thoracic esophagectomy with the use of stomach as the replacement organ of choice.     

Transhiatal esophagectomy for treatment of benign and malignant esophageal diseases

In 1978 the technique of transhiatal esophagectomy without thoracotomy was rediscovered and now it is widely used in certain, selected, cases. Between 1987 and 2003 we have performed transhiatal esophagectomy in 35 patients with intrathoracic esophageal disease: 13 (37.14%) for benign lesions of the esophagus and 22 (62.85%) for malignant lesions (22.72% upper, 9% middle and 68.18% lower third of the thoracic esophagus). The reconstruction was performed at the same operation in all but two patients. The esophageal substitute was stomach in all but one patient when left colon was used. Hospital mortality was 14.28% with one death due to uncontrollable intraoperative hemorrhage. Major complications included anastomotic leak, recurrent laryngeal nerve paralysis, atelectasis/pneumonia. The advantages of this approach over standard transthoracic esophagectomy are avoidance of a combined thoracoabdominal operation in a debilitated patient and fewer postoperative pulmonary complications and also avoidance of an intrathoracic esophagogastric anastomotic leak with high mortality due to mediastinitis.     

Short-segment colon interposition for end-stage achalasia

BACKGROUND: The reoperative procedures for achalasia vary. Repeat esophagomyotomy with or without antireflux procedure and esophageal resection of varying extent with reconstruction using stomach, jejunum, or colon have been reported. In this series, we have retrospectively reviewed our experience and reported the results with limited distal esophagectomy and short-colon interposition in the treatment of patients with recurrent symptoms of achalasia after prior failed esophagomyotomy. METHODS: Nine consecutive patients (5 men, 4 women; 27 to 74 years of age; mean, 52 years) with recurrent symptoms of achalasia and at least one failed prior esophagomyotomy underwent gastric cardiectomy, distal esophagectomy, and replacement with an at least 30-cm short-colon interposition through a left thoracoabdominal approach. Morbidity of the procedure and the length of hospital stay were recorded. The symptomatic evaluation, ability to have a meal, and overall patient satisfaction after the operations were assessed. RESULTS: Follow-up results were available in 8 patients. One patient had intestinal strangulation with graft failure 3 days after operation. Takedown of the graft and end-to-side esophagogastrostomy were successful. There was no mortality. Outcome assessment was completed at a median of 6 years (range, 1 to 12 years). Overall patient satisfaction was good in 6 patients, and fair and worse in 1 patient each. Most of the patients could have regular meals. Two patients had intermittent abdominal fullness after meals. Six of these 8 patients would have the operation again. CONCLUSIONS: Limited distal esophagectomy with short-colon interposition through a left thoracoabdominal approach is a safe and feasible alternative to near total esophagectomy in patients with achalasia who have prior failed esophagomyotomy. Improved alimentary function was observed in most of the patients after operation, which resulted in a better quality of life.     

Reoperative achalasia surgery

Forty-six patients with esophageal achalasia required reoperation between January 1970 and January 1986. Three of these patients required a second reoperative procedure, for a total of 49 reoperations. Indications for reoperation were inadequate myotomy, 17; gastroesophageal reflux, 14; concomitant antireflux operation, six; incorrect diagnosis, four; carcinoma of the esophagus, four; megaesophagus, three; and paraesophageal hernia, one. Various procedures were employed at the time of reoperation, including revision of the myotomy, takedown or revision of a previously performed wrap, fundoplication, and resection. Of the 48 patients available for follow-up study over an average postoperative period of 5 years, the condition of 38 (79%) was considered to have been improved by reoperation. The best results were obtained by revision or takedown of a previous wrap (an improvement rate of 88.9%) and radical resective procedures (89% to 100%). We conclude that for good results to be achieved after reoperative achalasia procedures, the preoperative diagnosis must be accurate, the operation should be performed early before the development of megaesophagus, and a short but complete esophagomyotomy must be performed, preferably without the addition of an antireflux procedure. Elimination or revision of a previously performed fundoplication can be expected to be followed by good results. The precise indications for radical resective procedures have yet to be defined clearly, but their wider application to carefully selected patients with postoperative achalasia seems justified.     

Choice of the method of video-thoracoscopic esophagectomy

Video-thoracoscopic esophagectomy was performed in 51 patients including 25 patients with esophageal cancer, 18 -- with cicatricial stenosis of the esophagus and 8 -- with esophageal achalasia of stage IV. Video-thoracoscopic esophagectomy and laparotomy for gastroplasty may be performed simultaneously with 2 surgery teams that reduce time of surgery. Simultaneous thoracoscopic and transhiatal approaches to the esophagus permit avoiding conversion in severe periesophagitis.     

Transhiatal esophagectomy for benign disease

Transhiatal esophagectomy without thoracotomy has been performed in 65 adult patients with dysphagia from benign esophageal disease: strictures (30), neuromotor dysfunction (24), acute iatrogenic perforation (five), acute caustic injury (four), and recurrent gastroesophageal reflux (two). Nearly 70% (45) had undergone at least one prior esophageal operation, and 26% (17) had a history of between two and four esophageal operations. The esophagus was replaced with stomach in 53 patients (82%), colon being used only when there was a history of either prior gastric resection or caustic injury to the stomach (10 patients). Intraoperative blood loss averaged 1,050 ml. Intraoperative complications included pneumothorax in 38 patients (58%) and a tracheal laceration in one patient. Postoperative complications included transient recurrent laryngeal nerve paresis (11 patients, 17%), chylothorax (four patients, 6%), anastomotic leak (four patients, 6%), and small bowel obstruction (two patients). There were five hospital deaths (8% mortality), none related to the technique of esophagectomy. Follow-up ranges from 1 to 84 months (average 28 months). Of 46 patients with a cervical esophagogastric anastomosis in the original esophageal bed, 42 have had an excellent functional result although 17 have required at least one postoperative esophageal dilation. Two have developed true anastomotic strictures. Clinically significant gastroesophageal reflux has not occurred. Transhiatal esophagectomy for benign disease is feasible and safe, even after multiple previous esophageal operations. The stomach appears to be a better visceral esophageal substitute than colon, because it allows an initially easier technical operation and superior long-term functional results.     

Laparoscopic treatment of recurrent dysphagia following transthoracic myotomy for achalasia

BACKGROUND: The choice of treatment of recurrent dysphagia following transthoracic myotomy is unclear. Often pneumatic dilatation is tried first, followed by esophagectomy in case of failure. We propose laparoscopic Heller myotomy as an alternative treatment for this group of patients. METHODS: Three patients underwent laparoscopic Heller myotomy for the treatment of recurrent dysphagia following transthoracic myotomy. The patients had undergone an average of 7 pneumatic dilatations (range, 2 to 10) prior to referral for surgery, without resolution of their dysphagia. RESULTS: All patients successfully underwent a laparoscopic myotomy on the right side of the esophagus with a Dor fundoplication. Good or excellent results were achieved in all patients. Average followup was 18 months. CONCLUSIONS: Laparoscopic Heller myotomy is a very effective treatment for patients who experience recurrent dysphagia following a transthoracic myotomy.     

Reoperation after failed esophagomyotomy for achalasia

Of 49 patients with achalasia treated surgically between 1975 and 1985, 12 (8 women, 4 men) had undergone transthoracic esophagomyotomy previously. Four had had concomitant upper gastrointestinal surgery. All 12 patients complained of dysphagia; other symptoms included regurgitation, nocturnal aspiration, heartburn, chest pain, vomiting, upper gastrointestinal bleeding and weight loss. The average time from initial operation to onset of symptoms was 9 months. Preoperative investigations and operative findings identified the cause of dysphagia as inadequate or healed esophagomyotomy with persistent or recurrent achalasia (eight patients--two had partially disrupted fundoplications contributing to their dysphagia), hiatus hernia with reflux esophagitis causing esophageal spasm or peptic esophageal stricture (two patients) and incorrect initial diagnosis and treatment (two patients). Treatment, with the aid of intraoperative manometry, included repeat Heller myotomy (five patients), Hill antireflux repair (four patients), takedown of Nissen fundoplication and extension of myotomy (two patients). The average follow-up was 16 months. Eight patients had good results, two required further operation and one underwent multiple dilatations postoperatively. The causes of recurrent dysphagia following surgery for achalasia are diverse and patients require individualized investigation and treatment. Remedial surgery for achalasia can correct postoperative dysphagia but results are less successful than those following an adequate initial operation.     

Three elderly patients with lower esophageal cancer successfully treated by transhiatal esophagectomy assisted by mediastinoscopy

Mediastinoscopy-assisted transhiatal esophagectomy recently has been applied in patients with intrathoracic esophageal cancer. Elderly patients with esophageal cancer experience several types of complications and often cannot undergo standard transthoracic esophagectomy. In this study, three elderly patients with preoperative complications underwent mediastinoscopy-assisted transhiatal esophagectomy for esophageal cancer located in the lower part of the esophagus. Patient 1 was an 80-year-old man with alcoholic liver cirrhosis. Patient 2 was a 78-year-old man with bronchial asthma. Patient 3 was an 81-year-old-man with diabetes mellitus and an atherosclerotic obstruction of the lower extremities. In these patients, mediastinoscopy-assisted transhiatal esophagectomy concomitant with reconstruction by means of a gastric tube was performed. Lymph node dissections of the middle and lower mediastinum and of the abdomen, including the regions surrounding the left gastric and celiac arteries, were performed. Postoperative complications developed only in patient 1; minor leakage of the esophagogastrostomy and high bilirubinemia were observed. Metastasis was detected in the lymph nodes surrounding the celiac artery in patient 1 and surrounding the left gastric artery in patients 2 and 3. Patient 2 died of pneumonia 18 months later, but the other patients have been well, without recurrence of the cancer after surgery. In conclusion, mediastinoscopy-assisted transhiatal esophagectomy has some benefits for elderly esophageal cancer patients who experience preoperative complications.     

Reflux patterns following limited myotomy without fundoplication for achalasia

Five patients with achalasia underwent limited myotomy without fundoplication. Surgery reduced mean lower esophageal sphincter resting pressure significantly (p less than .05) from 31 +/- 9.7 mm Hg to 16.1 +/- 8.2 mm Hg. Twenty-four-hour ambulatory esophageal pH studies demonstrated that the percentage of time the pH in the distal esophagus was below 4 was similar whether the patient was upright or supine (6.6 +/- 6.5% of total time upright vs. 9.1 +/- 12.7% of total time). Reflux events that occur in the supine position may be significant because of their prolonged duration resulting from the absence of normal secondary peristalsis in the body of the esophagus. Patients with achalasia who have undergone esophagomyotomy without fundoplication do not appear to experience more reflux than control subjects with normal esophageal function.