Manometric and radionuclide assessment of pharyngeal emptying before and after cricopharyngeal myotomy in patients with oculopharyngeal muscular dystrophy

Fifteen patients with oculopharyngeal muscular dystrophy underwent cricopharyngeal myotomy for palliation of dysphagia. The aim of this work was to assess the effectiveness of this operation by using a radionuclide pharyngeal emptying study as a new quantitative method in addition to clinical and manometric evaluation. Radionuclide study was performed with the patient in both the upright and the supine positions after ingestion of 15 ml of water labeled with sulfur colloid 99mTc. Computerized data were acquired at 0.5 second intervals for 15 minutes and a pharyngeal time-activity curve was generated. Four quantitative parameters were evaluated: the time for pharyngeal clearance of 25%, 50%, and 75% of the ingested radioactive water and the pharyngeal stasis at 15 minutes. Manometric studies were also performed before and after cricopharyngeal myotomy. The pharyngeal clearance of 25%, 50%, and 75% of the water and pharyngeal stasis at 15 minutes were all improved by cricopharyngeal myotomy, decreasing from 1.2 to 0.9 second (p less than 0.04), 4.2 to 2 seconds (p less than 0.005), 15 to 7 seconds (p less than 0.02), and 10.3% to 6% (p less than 0.01), respectively. Both pharyngoesophageal and tracheobronchial symptoms were also significantly improved by cricopharyngeal myotomy. Manometric evaluation showed a decrease of the upper esophageal sphincter closing pressure from 60.1 mm Hg before to 28.2 mm Hg after the operation (p less than 0.001), and the resting pressure decreased from 34.4 to 15.7 mm Hg (p less than 0.0005). Cricopharyngeal myotomy significantly improves both symptoms and pharyngeal emptying in patients with oculopharyngeal muscular dystrophy.     

Physiologic response to cricopharyngeal myotomy and diverticulum suspension

Ten patients who had a cricopharyngeal myotomy and diverticulum suspension for pharyngoesophageal diverticulum have been studied clinically, radiologically, and manometrically. There were no deaths or morbidity and all patients have achieved marked improvement of their symptoms. Before operation all patients but one had low resting tone in the upper esophageal sphincter and all patients had normal relaxation of the sphincter upon swallowing. The coordination of pharyngeal contraction and sphincter relaxation was normal in six patients and abnormal in four patients. After operations the only change was an increase in resting tone in seven patients, and there was no change in three patients. We conclude that cricopharyngeal myotomy and diverticulum suspension constitute an effective form of treatment for pharyngoesophageal diverticulum.     

Cricopharyngeal myotomy in upper esophageal sphincter dysfunction

Upper esophageal sphincter dysfunction is a diseases of a altered esophageal motility characterized by muscular functional obstruction with cervical dysphagia as the main clinical manifestation. It is complicated sometimes by incidental aspiration. Pulmonary infection and even choking. The cricopharyngeal anatomically acts as the upper esophageal sphincter Uncoordinated contraction between cricopharyngeal and pharyngeal muscle could be one of the mechanisms for the development of cervical dysphagia. Cricopharyngeal myotomy has been used to treat functional disorder of the upper esophagus. The rationale for such procedure is to relieve functional obstruction by producing a wide "Opening door" for the upper esophagus. This paper presents 5 cases suffering from severe dysphagia treated with above mentioned procedure. The result is satisfactory that all patients became symptom. Free another female patient who did not undergo the operation has died of sudden choking. Authors concluded that cricopharyngeal myotomy is a simple but effective procedure for treating upper esophageal sphincter dysfunction.     

Pharyngoesophageal dysfunctions. The role of cricopharyngeal myotomy

Eighteen patients were evaluated for primary symptoms of cervical dysphagia and/or laryngeal aspiration and subsequently had a cricopharyngeal myotomy. Twelve patients had a neurologic lesion as the cause of the symptoms. Four patients had a Zenker's diverticulum as demonstrated by barium contrast roentgenograms. Two patients complained of persistent suprasternal dysphagia following one or more antireflux repairs for gastroesophageal reflux disease. Esophageal manometry identified a pharyngoesophageal motor disorder in all but four patients, two of the four with Zenker's diverticulum and the two who had an antireflux procedure. The results show that cricopharyngeal myotomy should be reserved for patients with an identifiable motor disorder confined to the pharyngeal phase of swallowing, ie, failure of the pharyngeal pump or cricopharyngeal incoordination and/or incomplete relaxation. Exceptions to this rule are as follows: Zenker's diverticulum, in which an abnormality may not always be detected but of which the results of surgery demonstrate the effectiveness of this procedure; and pharyngoesophageal complaints associated with reflux, most of which resolve with the restoration of distal esophageal sphincter competence. In those few patients in whom these conditions persist, a cricopharyngeal myotomy may be beneficial. Caution should be used in applying the procedure to individuals who have had multiple antireflux repairs.     

Pathogenesis and treatment of Zencker's diverticulum

The aims of this study were: 1) To measure pharyngeal and upper oesophageal function manometrically at the same time as recording video images of the patient swallowing barium, in normal controls and patients with Zenker's diverticulum, and, 2) In those patients who progressed to surgery to biopsy the cricopharyngeus and compare the findings with biopsies from normal controls. Subjects were seated in front of a fluoroscope and video images of a barium swallow were synchronised with a multichannel recording catheter which contained 3 perfused side holes 1 cm apart (situated in the pharynx) and a 4 cm long perfused sleeve pressure sensor (positioned across the upper oesophageal sphincter). The coordination of the upper sphincter with swallowing, its relaxation, the pressures generated in the distal pharynx and the maximum luminal area of the open upper sphincter, were calculated for different volumes of barium swallowed in 11 patients with a Zenker's diverticulum (mean age 71 years, range 50-99) and 9 normal controls (mean age 65 years, range 55-86). Seven patients progressed to cricopharyngeal myotomy and their biopsies were compared with biopsies from 9 normal controls. In patients with Zenker's diverticulum intrapharyngeal pressures during barium swallows were significantly greater (p less than .05) and maximal luminal areas of the open sphincter were significantly less (p less than .05) than in control patients. In patients having a cricopharyngeal myotomy, intrapharyngeal pressures and maximum luminal areas returned to normal after surgery. The cricopharyngeus muscle of patients with a Zenker's diverticulum showed significantly increased fibrosis compared with normal controls.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sleeve recording of upper esophageal sphincter resting pressures during cricopharyngeal myotomy.

OBJECTIVE: The manometric effects of a 6-cm cricopharyngeal myotomy are recorded while the operation is being performed from cervical esophagus to the cricopharyngeus and then to the hypopharynx. SUMMARY BACKGROUND DATA: Cricopharyngeal myotomy is used in the treatment of oropharyngeal dysphagia of different causes. The operation decreases the resting pressure in the upper esophageal sphincter (UES). The components responsible for this decrease have not been clarified. METHODS: Fourteen patients with oropharyngeal dysphagia underwent a sleeve recording of the UES resting pressures under general anesthesia before and after sequential myotomy of the pharyngoesophageal junction. Patients were assessed in the awake state before and after the whole myotomy. RESULTS: Upper esophageal pressures remain unchanged after division of 2 cm of the cervical esophageal muscle. Section of 2 cm of the cricopharyngeal area results in a significant decrease of the sphincter resting pressure (p < 0.01). The division of 2 cm of hypopharyngeal muscle results in a further significant reduction of the resting pressure (p < 0.005). CONCLUSIONS: Extension of the cricopharyngeal myotomy over hypopharyngeal musculature produces a more significant decrease of UES resting pressure.     

Changes of esophageal motility after total laryngectomy.

OBJECTIVE: Total laryngectomy completely interrupts the continuity of the proximal digestive tract and may lead to derangement in esophageal motility. The purpose of this investigation was to find out how total laryngectomy changes the resting and the maximum contracting pressures of the upper esophageal sphincter muscle and how it affects the coordination of the contraction and the relaxation between the pharynx and the upper esophageal sphincter muscles. If changes in the function of the upper esophageal sphincter muscle should occur, this study will also demonstrate how it affects the motility of the esophagus and the lower esophageal sphincter muscle. METHODS: In an attempt to explain postoperative motility changes, the stationary pull through method of manometric evaluation was used to quantify the alteration in esophageal motility. For the manometric evaluation of the esophagus, a polyethylene catheter with 8 internal tubes was used. The study was performed on a group of 15 patients with total laryngectomy and 15 people without esophageal disease or symptoms as the control group. RESULTS: There was a statistically significant difference between the laryngectomy group and the control group for both the resting and maximum contraction pressures as well as for coordination and relaxation of the upper esophageal sphincter. (P < 0.05) In the laryngectomy group, 3 patients who complained of postoperative dysphasia showed more severe functional changes. The proximal esophageal body pressure and peristaltic waves were significantly decreased in the laryngectomy group. No significant difference between the laryngectomy group and the control group was noted in terms of the lower esophageal resting sphincter pressure and the postdeglution pressure. There also was no significant difference between the two groups in the degree of lower esophageal sphincter coordination and relaxation. CONCLUSION: From these results, it may be concluded that interruption of the cricopharyngeal muscle and pharyngeal plexus after laryngectomy not only may produce local derangement of upper esophageal sphincter function but also may produce abnormalities in peristalsis of the proximal esophageal body. However, the function of lower esophageal sphincter did not show any significant difference between the laryngectomy group and the control group.     

Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy

Twenty patients with cervical esophageal dysphagia were treated by cricopharyngeal myotomy. Of these 20 patients, ten had pharyngoesophageal diverticula, four had a hypertensive upper esophageal sphincter (UES), four had bulbar palsy, and two has miscellaneous forms of cricopharyngeal dysfunction. Preoperative esophageal manometric examination revealed mean UES pressures of 37.2 mmHg +/- 4.8 SEM in patients with diverticula-markedly lower (p = 0.01) than in normal patients (55.9 mmHg +/- 5.0 SEM). In patients with hypertensive UES the mean pressure was 166.2 mmHg +/- 13.4, significantly higher (p less than 0.001) than normal. Incoordination of the deglutitive response of the UES characterised by premature relaxation and contraction was present in all patients with diverticula and in one other patient. Another patient exhibited incomplete sphincteric relaxation (achalasia). A 4-5 cm myotomy of the cricopharyngeus muscle and adjacent esophageal muscle was performed in all patients. On the patients with diverticula two also had diverticulectomy. No patient with bulbar palsy was benefited. All other patients were relieved of dysphagia by the operation, with the exception of one patient with a diverticulum. A subsequent diverticulectomy was required in this patient. Postoperative manometric examination revealed an average decrease in UES pressure of 63% and an average decreased in length of the high pressure zone of 1.4 cm.     

Long-term results of cricopharyngeal myotomy in oculopharyngeal muscular dystrophy.

OBJECTIVE: To analyze long-term results of extramucosal cricopharyngeal myotomy in oculopharyngeal muscular dystrophy. STUDY DESIGN: The preoperative and postoperative evaluations including symptoms, type of feeding, weight, and functional examinations were retrospectively evaluated in 39 patients. Results were defined postoperatively as successful, partial, or failed. SETTING: University hospital. RESULTS: In the short term, 25 patients showed a complete remission of symptoms, 10 showed a marked improvement, and 4 exhibited no improvement at all (success rate of 90%). Long-term evaluation during a mean follow-up of 4 years showed that of the 35 improved patients, 12 exhibited a recurrence of dysphagia (mean time of 39 months). In 3 of these 12 patients, a revision transmucosal endoscopic cricopharyngeal myotomy was performed with a successful outcome in 2. Of the 4 patients who initially showed no improvement, 1 was improved by transmucosal myotomy. CONCLUSION: Extramucosal cricopharyngeal myotomy improves dysphagia in oculopharyngeal muscular dystrophy patients during the first few years but one third of the patients exhibited a recurrence of symptoms within 3 years. Revision by transmucosal endoscopic myotomy may be performed. EBM rating: C-4.     

Cricopharyngeal dysfunction.

The aim of the study was to determine the manometric patterns in dysphagic patients with radiologic evidence of upper esophageal sphincter (UES) dysfunction. Nineteen patients with radiographic abnormalities of the UES underwent measurement of several parameters of UES tonic pressure and pharyngoesophageal water swallow dynamics. At least two UES tonic pressures were elevated in six subjects, compared with a control group of 67 healthy volunteers. No patients had UES achalasia. The cricopharyngeal impression in the remaining patients may represent muscular hypertrophy or deficiency of UES opening, despite manometric relaxation, but its relationship to the patient's symptoms remains unknown. Cricopharyngeal myotomy appears to be a reasonable treatment for patients with manometric UES hypertonicity.     

Pre- and postoperative manometric studies in diffuse esophageal spasm.

Since January, 1972, the authors have operated upon 4 patients with idiopathic diffuse exophageal spasm. Clinical details and barium studies are included. Extramucosal myotomy extending from the gastric fundus to the aortic arch was done in each case. Pre- and postoperative manometric studies were carried out in all. After operation in each patient the dysphagia and substernal pain disappeared and in 3 patients radiological patterns changed. The myotomy was associated with marked fall of contractile wave pressures in the body of esophagus. The basal pressures of the esophageal body elevated, in 2 cases fell after the myotomy; in 2 with normal preoperative pressure it remained unchanged. At the lower esophageal sphincter the resting and yield pressures remained similar to the preoperative readings but the myotomy produced a disappearance of the relaxation and contraction pressure. The authors conclude that with myotomy they cannot correct the nature of the functional disorder but, by reducing the amplitude of the waves and lowering the resting pressure if elevated, they can relieve the patient's symptoms.     

次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂临床观察(附150例报告)

目的观察次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂临床疗效及其对肛门功能的影响。方法治疗组选取Ⅲ期肛裂患者150例,均采用次侧方内括约肌切开加双缘结扎术治疗,观察创口愈合时间、随访6个月的复发率及测定手术前后肛门直肠压力,并与健康对照组比较。结果所有患者均痊愈出院,创口平均愈合时间(16±2.87)d,随访6个月无复发病例;术前肛管静息压较正常人显著升高(P0.05),肛管舒张压较前显著降低(P0.05),肛管最大收缩压及肛管自主收缩持续时间与正常人比较无明显差异(P0.05);术后肛管静息压较术前明显降低(P0.05),肛管舒张压较前明显升高(P0.05),肛管最大收缩压及肛管自主收缩持续时间与术前比较无明显差异(P0.05);术后肛管静息压、肛管舒张压、肛管最大收缩压及肛管自主收缩持续时间与正常人比较无明显差异(P0.05)。结论次侧方内括约肌切开加双缘结扎术治疗Ⅲ期肛裂疗效显著,能有效地解除内括约肌痉挛,改善肛裂溃疡面的供血不足,促进肛裂的愈合。     

Acetylcholine receptor density in human cricopharyngeal muscle and pharyngeal constrictor muscle

BACKGROUND: Upper esophageal sphincter resting tone is reduced during partial neuromuscular block, whereas contraction of the pharyngeal constrictor muscle is only slightly affected. We hypothesized that this difference may arise from differential nicotinic acetylcholine receptor (nAChR) density, the density supposedly being lower in the more sensitive cricopharyngeal muscle than in the resistant pharyngeal constrictor muscle. The aim of this study was to determine the density of nAChR in the main component of the upper esophageal sphincter, the cricopharyngeal muscle, and in the pharyngeal constrictor muscle. METHOD: After approval by the institutional ethics committee and informed consent, muscle specimens were obtained from five patients undergoing surgery with laryngectomy for malignancies of the larynx or thyroid gland. None had received radiation therapy to the affected area. The nAChR from these tissue specimens were solubilized and incubated with 125I-alpha-bungarotoxin. The quantity of radioligand-receptor complex was measured by radioactive decay in a liquid scintillation counter. The receptor density was expressed as femtomoles per milligram of protein (fmol/mg protein). RESULTS: The nAChR density was determined to 6.8 (3.5) fmol/mg protein (mean (SD)) in the cricopharyngeal muscle and 5.6 (2.1) fmol/mg protein in the pharyngeal constrictor muscle (P = 0.22). Although we could not find any difference in mean nAChR density, contrary to our hypothesis, the density in four of the five patients was higher in the cricopharyngeal muscle than in the pharyngeal constrictor muscle. CONCLUSION: Our results indicate that the density of nicotinic acetylcholine receptors is similar in the cricopharyngeal muscle and in the pharyngeal constrictor muscle. Nicotinic acetylcholine receptor density, as determined by 125I-alpha-bungarotoxin assay, cannot explain the difference in response to neuromuscular blocking drugs between the investigated muscles.     

Pharyngeal function and airway protection during subhypnotic concentrations of propofol, isoflurane, and sevoflurane: volunteers examined by pharyngeal videoradiography and simultaneous manometry.

BACKGROUND: Anesthetic agents alter pharyngeal function with risk of impaired airway protection and aspiration. This study was performed to evaluate pharyngeal function during subhypnotic concentrations of propofol, isoflurane, and sevoflurane and to compare the drugs for possible differences in this respect. METHODS: Forty-five healthy volunteers were randomized to receive propofol, isoflurane, or sevoflurane. During series of liquid contrast bolus swallowing, fluoroscopy and simultaneous solid state videomanometry was used to study the incidence of pharyngeal dysfunction, the initiation of swallowing, and the bolus transit time. Pressure changes were recorded at the back of the tongue, the pharyngeal constrictor muscles, and the upper esophageal sphincter. After control recordings, the anesthetic was delivered, and measurements were made at 0.50 and 0.25 predicted blood propotol concentration (Cp50(asleep)) for propofol and 0.50 and 0.25 minimum alveolar concentration (MAC)(awake) for the inhalational agents. Final recordings were made 20 min after the end of anesthetic delivery. RESULTS: All anesthetics caused an increased incidence of pharyngeal dysfunction with laryngeal bolus penetration. Propofol increased the incidence from 8 to 58%, isoflurane from 4 to 36%, and sevoflurane from 6 to 35%. Propofol in 0.50 and 0.25 Cp50(asleep) had the most extensive effect on the pharyngeal contraction patterns (P < 0.05). The upper esophageal sphincter resting tone was markedly reduced from 83 +/- 36 to 39 +/- 19 mmHg by propofol (P < 0.001), which differed from isoflurane (P = 0.03). Sevoflurane also reduced the upper esophageal sphincter resting tone from 65 +/- 16 to 45 +/- 18 mmHg at 0.50 MAC(awake)(P = 0.008). All agents caused a reduced upper esophageal sphincter peak contraction amplitude (P < 0.05), and the reduction was greatest in the propofol group (P = 0.002). CONCLUSION: Subhypnotic concentrations of propofol, isoflurane, and sevoflurane cause an increased incidence of pharyngeal dysfunction with penetration of bolus to the larynx. The effect on the pharyngeal contraction pattern was most pronounced in the propofol group, with markedly reduced contraction forces.     

Digital cineradiology in the diagnosis and surgical treatment of pharyngo-oesophageal junction motor disorders

The aim of the study was to report our experience with the use of radiology in functional disorders of the cricopharyngeal muscle and their surgical therapy using digital cineradiology. Five-hundred and seventy dysphagic patients underwent dynamic study of the oral and pharyngeal phases of swallowing (Videofluoroscopic Swallowing Study, VFSS). A motor disorder of the cricopharyngeal muscle was diagnosed by videofluorography in 19 patients: the disorder was mild in 8, moderate in 7 and severe in 4. Two of these underwent cricopharyngeal myotomy, with an improvement in their dysphagia and swallowing mechanisms. VFSS provides a morphological and functional view of the aero-digestive tracts: this is essential in the diagnosis of cricopharyngeal dysfunction and is capable of revealing the related laryngeal penetration and tracheal aspiration. VFSS must always include an oesophageal phase study because of the known clinical and physico-pathological correlations between the gastro-oesophageal junction and the upper oesophageal sphincter. On the basis of our experience we believe that VFSS could be used as a primary investigation, followed by motility studies, and that it may be a useful complementary procedure both in the diagnosis of pharyngo-oesophageal junction motor disorders and with a view to surgical indications.     

Surgical indications in cricopharyngeal dysfunction]

In 1989, five patients were treated for a cricopharyngeal dysfunction by cervical myotomy. In the past, due to extremely limited indications for surgery, repeated efforts of conservative treatment had been attempted in patients with idiopathic cricopharyngeal dysfunction and tracheopulmonary aspiration and/or permanent inability of oral nourishment. These patients underwent surgery after an interdisciplinary clinical assessment. Four out of five patients showed immediate improvement of their serious symptoms. Cervical myotomy is not expected to be successful in patients with insufficient oropharyngeal propulsion, as we could see in one female patient with severe upper oesophageal sphincter spasm. According to the literature and to our results, approximately 70 to 90% of the patients with idiopathic dysfunction of the cricopharyngeal muscle, who underwent surgery, showed significant improvement or even recovery. Due to the multifactoral genesis of the cricopharyngeal dysfunction it is understandable, that the surgical result is heavily dependent on the preoperative interdisciplinary diagnosis. In summary, for idiopathic cricopharyngeal dysfunction with complications we recommend the early and technically simple operation.     

Zenker's diverticulum. Long-term results after surgical therapy]

Twenty-one patients were treated for Zenker's diverticulum in the Würzburg University Department of Surgery between 1977 and 1989. Surgery was done in 15 cases (8 single-session resections with myotomy of the upper esophageal sphincter, and 7 resections without myotomy). The postoperative course was uneventful in 73%. Wound infection developed in 2 cases, and suture insufficiency and transient paralysis of the recurrent nerve in one each. In 3 patients, postoperative x-ray prior to release from the hospital revealed retention of contrast medium in a discrete, pocket-like protrusion between the cricoid and the pharynx. Follow-up was done after a mean interval of 4 years (range: 5 months-10.5 years) in 10 of the 15 operated patients. Two of them developed relapses about 1-1.3 cm in size within 8 months and 7 years, resp. Myotomy had not been done in either case. Neither patient had complaints. Esophageal manometry was performed in 6 patients. Resting tone of the upper esophageal sphincter was clearly diminished at 12-30 mm Hg (normal 40-50 mm Hg); maximum contraction pressure was also reduced at 30-75 mm Hg (normal 90-110 mm Hg). However, the decisive factor was the exact temporal coordination of pharyngeal contraction with sphincter relaxation. For this reason it is our unconditional recommendation that myotomy of the upper esophageal sphincter be regarded as an essential step in resection of Zenker's diverticula.     

Risk factors in patients undergoing cricopharyngeal myotomy

BACKGROUND: Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death. METHODS:: A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon. RESULTS: A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1.2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10.3 per cent). CONCLUSION: Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.     

Clinical features and oesophageal motility in patients with tight fundoplication.

OBJECTIVE: Tight fundoplication is a well known complication of surgery for gastroesophageal reflux. We have noted, in clinical experience, that some patients operated for gastro-oesophageal reflux develop pharyngo-oesophageal dysphagia. This study was undertaken to elucidate, by comparing motility data in patients with and without tight fundoplication, the pathophysiologic characteristics of the swallowing mechanism and to clarify the cause of dysphagia in these patients. METHODS: Sixteen patients with postoperative persistent dysphagia following a fundoplication have been studied, of those 10 presented a lower oesophageal sphincter resting pressure above or equal to 30 mmHg (group A). Clinical work-up included a questionnaire, oendoscopy, manometry and barium meal or video-roentgenography. Oesophageal manometry was performed using a slow pull through technique while the stationary pull through technique was used for the pharyngo-oesophageal segment. The following parameters were evaluated: (a) amplitude of pharyngeal contraction; (b) upper oesophageal sphincter resting pressure; (c) amplitude of upper oesophageal sphincter contraction; (d) amplitude of oesophageal contraction; (e) lower oesophageal sphincter resting pressure. The results were compared to those of 21 patients who had a fundoplication with normal lower oesophageal sphincter pressure (group B). RESULTS: in group A there were three males and seven females, with a mean age of 51 years (ranging from 28 to 60 years). Previous operations were Nissen in two and Nissen Rossetti in eight patients. Three out of 10 patients of group A presented pharyngo-oesophageal dysphagia. Mean lower oesophageal sphincter 36 versus 21 mmHg and upper oesophageal sphincter 86 versus 42 mmHg resting pressure, pharyngeal 147 versus 76 mmHg and oesophageal amplitude, upper oesophageal contraction 251 versus 103 mmHg were significantly higher in patients of group A versus group B. An increased number of repetitive contractions was also found in group A. The presence of a strong correlation was demonstrated between the pharyngeal amplitude and the closing tone of the upper oesophageal sphincter (R2 0.742 and R2 0.739) in both groups. CONCLUSION: Tight fundoplication is, in our experience, always associated with total fundoplication. The appearance of pharyngo-oesophageal dysphagia in the postoperative period in patients operated on to correct gastroesophageal reflux using a total fundoplication, should not be under-estimated because it suggests an obstruction of the distal oesophagus.     

Functional Assessment of the Pharynx at Rest and during Swallowing in Partially Paralyzed Humans: Simultaneous Videomanometry and Mechanomyography of Awake Human Volunteers

Background: Functional characteristics of the pharynx and upper esophagus, including aspiration episodes, were investigated in 14 awake volunteers during various levels of partial neuromuscular block. Pharyngeal function was evaluated using videoradiography and computerized pharyngeal manometry during contrast bolus swallowing.

Methods: Measurements of pharyngeal constrictor muscle function (contraction amplitude, duration, and slope), upper esophageal sphincter muscle resting tone, muscle coordination, bolus transit time, and aspiration under fluoroscopic control (laryngeal or tracheal penetration) were made before (control measurements) and during a vecuronium-induced partial neuromuscular paralysis, at fixed intervals of mechanical adductor pollicis muscle train-of-four (TOF) fade; that is, at TOF ratios of 0.60, 0.70, 0.80, and after recovery to a TOF ratio > 0.90.

Results: Six volunteers aspirated (laryngeal penetration) at a TOF ratio < 0.90. None of them aspirated at a TOF ratio > 0.90 or during control recording. Pharyngeal constrictor muscle function was not affected at any level of paralysis. The upper esophageal sphincter resting tone was significantly reduced at TOF ratios of 0.60, 0.70, and 0.80 (P < 0.05). This was associated with reduced muscle coordination and shortened bolus transit time at a TOF ratio of 0.60.