Long-term outcome of esophageal myotomy for achalasia

AIM:Modified Heller‘s myotomy is still the first choice for achalasia and the assessment of surgical outcomes is usually made based on the subjective sensation of patients.This study was to objectively assess the long-term outcomes of esophageal myotomy for achalasia using esophageal manometry, 24-hour pH monitoring,esophageal scintigraphy and fiberoptic esophagoscopy.METHODS:From February 1979 to October 2000, 176 patients with achalasia underwent modified Heller‘s myotomy, including esophageal myotomy alone in 146 patients, myotomy in combination with Gallone or Dor antirefiux procedure in 22 and 8 patients, respectively. Clinical score,pressure of the lower esophageal sphincter (LES),esophageal clearance rate and gastroesophageal reflux were determined before and i to 22 years after surgery.RESULTS: After a median follow-up of 14 years, 84.5% of patients had a good or excellent relief of symptoms,and clinical scores as well as resting pressures of the esophageal body and LES were reduced compared with preoperative values (P<0.001).However,there was no significant difference in DeMeester score between pre-and postoperative patients(P=0.51).Esophageal transit was improved in postoperative patients, but still slower than that in normal controls. The incidence of gastroesophageal reflux in patients who underwent esophageal myotomy alone was 63.6% compared to 27.3% in those who underwent myotomy and antirefiux procedure (P=-0.087). Three (1.7%) patients were complicated with esophageal cancer after surgery.CONCLUSION: Esophageal myotomy for achalasia can reduce the resting pressures of the esophageal body and LES and improve esophageal transit and dysphagia. Myotomy in combination with antireflux procedure can prevent gastroesophageal reflux to a certain extent,but further randomized studies should be carried out to demonstrate its efficacy.     

Self-expanding metal stents in the palliation of malignant dysphagia: outcome analysis in 100 consecutive patients.

SUMMARY. Patients with inoperable esophageal malignancy often undergo palliative self-expanding metal stent insertion. This analysis of cases shows that although such stents provide good palliation of dysphagia, complications frequently occur. Complications reported were pain after insertion, bleeding, food bolus impaction, stent migration and increased gastroesophageal reflux. Furthermore, in patients with esophageal adenocarcinoma, survival was less if the distal end of the stent entered the stomach, rather than lying entirely within the esophagus. Reduced survival, in this group with gastroesophageal junction tumors, may be a result of increased gastroesophageal reflux leading to pulmonary aspiration. Stents incorporating an antireflux valve have been shown to reduce symptomatic gastroesophageal reflux. It may be that such valves offer a survival advantage where stent insertion ablates the function of the lower esophageal sphincter. Further studies are needed to assess the role of antireflux stents on survival in patients with gastroesophageal junction tumors.     

Esophageal Biopsy Does Not Predict Clinical Outcome after Percutaneous Endoscopic Gastrostomy in Children

Clinically symptomatic gastroesophageal reflux may occur after percutaneous endoscopic gastrostomy (PEG). Preoperative evaluation for gastroesophageal reflux does not reliably predict those individuals who will develop reflux unresponsive to medical management after PEG. Esophageal histology at the time of PEG might be used to identify patients at risk for developing intractable gastroesophageal reflux. The study aim was to correlate the clinical outcome after PEG with esophageal histology at the time of PEG insertion. A retrospective review of 68 consecutive children who had an esophageal biopsy obtained at the time of PEG insertion was undertaken. Preoperative evaluation, esophageal histology, and clinical outcomes were compared. Preoperative gastroesophageal reflux was present in 23% of upper gastrointestinal series performed, in 10% of pH probe studies, and in 29% of reflux scans. Histology was normal in 57% of esophageal biopsies obtained at the time of PEG insertion. Symptomatic gastroesophageal reflux requiring antireflux surgery or conversion to gastrojejunostomy developed in 10% of patients after PEG placement. Only one of these patients had esophagitis on biopsy. In conclusion, preoperative esophageal histology does not reliably predict the development of symptomatic gastroesophageal reflux after PEG placement.     

Barrett's esophagus in childhood

This study describes the clinical, radiologic, esophageal function test, endoscopic, and histologic findings of Barrett's esophagus in 11 children aged 6-14 yr. All had long-standing symptoms of gastroesophageal reflux, which had begun in the first year of life in 10 of the 11. Eight of the 11 patients had mid or upper esophageal strictures and 10 of the 11 required fundoplication. Most patients had low lower esophageal sphincter pressures and abnormal pH probe studies. Only 6 of the 11 children had the characteristic pink-red appearance of the mucosa at endoscopy. Fifty endoscopic biopsy specimens taken at multiple levels in the esophagus contained columnar-lined epithelium above the gastroesophageal junction. Five of the patients had specialized (intestinal-type) epithelium as part of the histologic spectrum. The clinical expression of Barrett's esophagus in children is similar to that in adults except that strictures appear to be more common in children, and the endoscopic appearance of the mucosa is not always typical in color. As in adults, gastroesophageal reflux appears to be the etiology. In children beyond infancy, Barrett's esophagus is the most common indication for antireflux surgery at our institution. Biopsy specimens should be taken from multiple levels in the esophagus to avoid overdiagnosis and to establish the diagnosis with certainty.     

Esophageal motor abnormalities in gastroesophageal reflux and the effects of fundoplication

Recordings of esophageal manometry obtained from 18 healthy control subjects and 32 patients with gastroesophageal reflux disease both before and after fundoplication were assessed. Preoperatively, the patients had a mean lower esophageal sphincter pressure at rest that was significantly lower (p less than 0.001) than that observed in the control group. The amplitude of peristaltic contractions, elicited by wet swallows, varied along the length of the esophagus. In patients with gastroesophageal reflux disease, the mean amplitudes recorded from the upper, middle, and lower esophagus were significantly lower (p less than 0.001) than those recorded from control subjects. No significant differences were observed between those patients with (53%) and without preoperative endoscopic evidence of esophagitis. After antireflux surgery (modified Nissen fundoplication), the mean amplitude of peristaltic contractions increased significantly (p less than 0.001) at all levels of the esophagus and were not significantly different from control values. This study describes motor abnormalities in the body of the esophagus associated with gastroesophageal reflux disease. These may arise secondary to gastroesophageal reflux inasmuch as they disappear after fundoplication.     

Controversies in the treatment of gastroesophageal reflux and achalasia

The immense success of laparoscopic surgery as an effective treatment of gastroesophageal reflux disease (GERD) and achalasia has established minimal invasive surgery as the gold standard for these two conditions with lower morbidity and mortality, shorter hospital stay, faster convalescence, and less postoperative pain. One controversy in the treatment of GERD evolves around laparoscopic antireflux surgery (LARS) as the preferred treatment for Barrett's esophagus and the procedure's potential to reduce the risk of adenocarcinoma of the esophagus. GERD has also been associated with respiratory symptoms, asthma and laryngeal injury, and a second controversy prompts discussions about whether total or partial fundoplication is the more appropriate treatment for GERD. A new and promising alternative in the treatment of GERD is endoluminal therapy. Three types of this new treatment option will be discussed: radiofrequency energy delivered to the lower esophageal sphincter, the creation of a mechanical barrier at the gastroesophageal junction, and the direct endoscopic tightening of the lower esophageal sphincter. Laparoscopic surgery is discussed not only as a very effective treatment for GERD but also as permanent cure for achalasia. This review analyzes the three most important treatment options for achalasia: medications, pneumatic dilatation, and surgical therapy. Medications as the only true non-invasive option in the treatment of achalasia are not as effective as LARS because of their short half-life and variable absorption due to the poor esophageal emptying. The second treatment option, pneumatic dilatation, involves the stretching of the lower esophagus and is still considered the most effective non-surgical treatment for achalasia. Finally, surgical therapy for achalasia and the two major controversies concerning this laparoscopic treatment are discussed. The first involves the extent to which the myotomy is extended onto the stomach, and the second concerns the necessity and type of antireflux procedure to prevent GERD after myotomy. LARS and laparoscopic Heller myotomy are the agreed upon as the gold standards for surgical treatment of GERD and achalasia, respectively. In the hands of an experienced laparoscopic surgeon both are safe and effective treatments for patients with excellent subjective and objective long-term results with at least 90% patient satisfaction.     

Return of esophageal peristalsis after Heller's myotomy for idiopathic achalasia

A 23-year-old male was diagnosed as having idiopathic achalasia on the basis of clinical, radiologic, endoscopic, and manometric evaluation. He underwent a Heller's myotomy with 180 degrees posterior fundoplication as an antireflux procedure, and he did well subsequently. On reexamination one month later, return of peristaltic activity throughout the body of the esophagus was shown on manometric studies. Two years after the operation, peptic esophagitis was diagnosed by esophagoscopy, and the acid reflux test confirmed the existence of gastroesophageal reflux. To our knowledge, this represents the first reported case of return of esophageal peristalsis in idiopathic achalasia after surgical myotomy.     

Functional analysis of long‐term outcome after Heller's myotomy for achalasia

Treatment of achalasia aims at reducing the pressure of the lower esophageal sphincter (LES) and palliate symptoms. Our objective in this study was to investigate functional changes of the esophagus after Heller myotomy and evaluate their influence on postoperative gastroesophageal reflux and esophageal morphologic changes. Between 1980 and 2003, 216 patients with achalasia underwent Heller myotomy, associated with anterior partial fundoplication (Dor fundoplication). Preoperative and long‐term outcome data were collected from these patients at our hospital. The objective was to analyze esophageal functional results after Heller myotomy in the long term. Results were classified as excellent, good, fair, or poor, according to Vantrappen and Hellemans’ modified classification. One‐year, 2‐year, 5‐year, 10‐year, and 20‐year postoperative follow‐up information was available in 100% of all patients, 91.7%, 85.1%, 60%, 52.6%, and 45.9%, respectively. There were no perioperative deaths. One year after the surgery, all patients had a significant reduction in symptoms of dysphagia and regurgitation. Five years, 10 years, 15 years, and 20 years after surgery, there were 77.2% of patients (142 in 184), 68.1%, 57.1%, and 54.5%, respectively, who were satisfied (excellent to good) with surgery. No esophageal peristalsis was demonstrated in patients during follow‐up. Contractile waves in the body of the esophagus were simultaneous. The difference in the distal esophageal amplitude, the LES relaxation rate, and LES pressures in the anterior wall and/ or two sides was significant (P < 0.05) when compared before and after operation. However, there was no significant difference in the LES length and LES pressure in the posterior side. The change of direction of the LES pressure and the relaxation of LES correlate with long‐term outcomes. Postoperative gastroesophageal reflux rates, including nocturnal reflux, increased with time. The percentage of patients whose esophageal diameter became normal or remained mildly increased with time in the first 10 years after surgery changed significantly. Myotomy is an effective way to palliate symptoms in patients with achalasia. Adequate myotomy can lead to reduction of LES pressure in two or three directions, which may facilitate esophageal emptying by gravity. Surgical intervention does not lead to the return of esophageal peristalsis. Functional damage of LES in patients with achalasia is irreversible.     

Progression of Barrett's mucosa to adenocarcinoma after antireflux surgery: Radiologic-pathologic correlation

A patient with Barrett's esophagus progressed to adenocarcinoma, despite antireflux operation, adequate medical therapy, and regular yearly surveillance by esophageal function tests and endoscopic biopsy. This case stresses the need for closer follow-up of patients with Barrett's esophagus even after adequate control of gastroesophageal reflux by anti-reflux surgery.     

The impact of antireflux surgery on oxidative stress of esophageal mucosa caused by gastroesophageal reflux disease: 4-yr follow-up study

BACKGROUND AND AIM: Oxidative stress to esophageal mucosa plays a key role in the pathogenesis of gastroesophageal reflux disease (GERD), Barrett's esophagus, and adenocarcinoma. We investigated whether successful antireflux surgery eliminates oxidative stress. METHODS: Oxidative stress of esophageal mucosa was measured in 20 GERD patients, before antireflux surgery and 6 and 48 months after it, and compared with normal controls' mucosa (N = 9). Preoperatively, 12 of the 20 had erosive esophagitis or Barrett's metaplasia. Postoperatively, healing of GERD was verified with endoscopy and 24-h pH monitoring. We measured oxidative stress by myeloperoxidase activity (MPA), superoxide dismutase activity, and glutathione content (GSH) in distal esophagus samples from endoscopy. RESULTS: No patient had reflux symptoms after surgery, and pH measurements had normalized. MPA in the distal esophagus decreased (p < 0.05) after successful antireflux surgery, but remained higher than that of controls both 6 months and 4 yr postoperatively (p < 0.05). At all time-points, MPA was higher in patients with preoperatively detected erosive reflux disease (ERD) as compared to non-erosive reflux disease (NERD) (p < 0.01, p < 0.05, and p < 0.05, respectively). GSH values decreased with time only in NERD. At all time-points, GSH levels in distal esophagus were lower than control levels. CONCLUSIONS: Antireflux surgery can heal macroscopic esophagitis but cannot fully reverse the oxidative stress (as reflected by MPA and GSH) upon the distal esophageal mucosa.     

Barrett's esophagus: a review

Barrett's esophagus may be defined as a columnar epithelium-lined distal esophagus. As a frequently recognized complication of gastroesophageal reflux, Barrett's esophagus has become a diagnosis of general clinical concern. Factors governing the development of this complication in patients with gastroesophageal reflux are unknown but may be congenitally determined in part. When symptoms are present, they are due to the complications of reflux, such as esophagitis, stricture, ulcer, or bleeding. Barrett's esophagus may be suspected on the basis of results of a barium meal test, endoscopy, or isotope scanning. Iodine staining at endoscopy or manometrically guided biopsy helps to localize the abnormal mucosal segment. The diagnosis is proved by biopsy. The columnar epithelium of Barrett's esophagus has a malignant predisposition, and, once the diagnosis is made, periodic endoscopy, with biopsy and cytologic study, is indicated. The treatment of Barrett's esophagus is directed toward objective cessation of gastroesophageal reflux. In refractory cases, antireflux surgery improves symptoms and complications from reflux, but the columnar epithelium generally persists along with its malignant potential. It is not known whether effective antireflux treatment will lower the incidence of adenocarcinoma.     

Gastroesophageal reflux disease: the ongoing saga of pill versus knife

The Department of Veterans Affairs Cooperative Studies Program conducted a trial comparing the efficacy of medical and surgical therapy for complicated gastroesophageal reflux disease (GERD) in the 1980s and found surgery to be more effective in improving symptoms and endoscopic signs of esophagitis for up to 2 yr. To determine the long term efficacy of medical and surgical therapies, Spechler et al. conducted a follow-up of the trial. Ninety-one medical and 38 surgical patients of the original 247 patients were asked to maintain 2-wk GERD symptoms diaries (1 wk on and 1 wk off antireflux medications). Gastroesophageal Reflux Disease Activity Index (GRACI) scores were calculated, with the range being 74 (no symptoms) to 172 (worst symptoms). Patients also underwent upper endoscopy and 24-hr esophageal pH monitoring after stopping antireflux medications. One week after discontinuing medications, Gastroesophageal Reflux Disease Activity Index scores were found to be significantly lower in the surgical group (82) than in the medical group (96). There was no difference in the grade of esophagitis, occurrence of esophageal adenocarcinoma, frequency of treatment of esophageal strictures, quality of life scores, and overall satisfaction with antireflux therapy. More deaths were reported in the surgical group, though none of the deaths were related to surgery. Ninety-two percent of the medical and 62% of the surgical patients had continued to use antireflux medications regularly over a mean follow-up of 10.6 and 9.1 yr, respectively. Cancer incidence among patients with severe GERD without Barrett's esophagus was found to be 0.07%/yr. The authors concluded that antireflux surgery should not be advised with the expectation that GERD patients will no longer require antireflux medications or that the surgery will prevent esophageal cancer among patients with GERD and Barrett's esophagus.     

Laparoscopic fundoplication in patients with an aperistaltic esophagus and gastroesophageal reflux

A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.     

Gastroesophageal reflux disease and Barrett��s esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett’s esophagus), and adenocarcinoma. Barrett’s esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15–20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett’s esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.     

Laparoscopic myotomy in achalasia: intraoperative evidence for myotomy of the gastric cardia

The myotomy performed for achalasia of the esophagus should divide all of the constricting, diseased muscular elements that obstruct the esophagogastric junction (EGJ). Whether the disease process includes proximal gastric as well as esophageal components is as yet unclear, but anatomic evidence complemented by clinical data suggest that the disease process does not end at the evanescent and poorly defined EGJ. Clinical reports from enthusiastic proponents of a particular operative approach for achalasia have not been illuminating in this regard, because all patients are improved to some degree post-operatively, and there are no objective parametric standards for the evaluation of swallowing function. This study reports a series of patients in whom endoscopic viewing was used to judge the adequacy of myotomy after ‘esophageal’ myotomy. The question posed by this study was, ‘Does esophageal myotomy remove all constricting elements at the gastroesophageal junction?’ Laparoscopic myotomy was performed in 48 patients with a diagnosis of achalasia; these patients are the most recent in a total cohort of 72 patients operated upon for achalasia during the past 20 years. Myotomy was begun on the esophagus, and extended to the esophagogastric junction; anatomic landmarks, including the appearance of submucosal veins, guided the initial dissection. Intraoperative endoscopy was then performed to determine whether there was residual constriction of the channel between the esophagus and stomach; if so, myotomy was extended onto the gastric cardia until visual evidence of obstruction had disappeared. All patients had either Toupet fundoplication or Dor fundoplication after myotomy. There were obvious constricting elements distal to the gastroesophageal junction in 90% of the patients. These patients required extension of the myotomy onto the stomach for an average of 15 mm. All but one patient had improved swallowing post-operatively. Eight patients required ‘stretch’ of the distal esophagus/cardia within the first year post-operatively; one patient was reoperated for fibrous scar obstruction of the distal esophagus. Esophageal myotomy limited to the esophageal muscle does not remove all constricting elements at the gastroesophageal junction; as a result, the extended myotomy must be complemented by an antireflux procedure during operations for achalasia.     

Importance of bile reflux in Barrett's esophagus

Barrett's esophagus (BE) is an acquired condition in which the squamous epithelial lining of the lower esophagus is replaced by a columnar epithelium due to chronic gastroesophageal reflux. The role of acid and bile in the development of esophageal mucosal injury and the formation of BE is controversial. Acid and pepsin are unquestionably important in causing mucosal damage and BE formation in both animal models and humans. Animal studies suggest the potential for synergistic damage from conjugated bile acids and gastric acid, as well as from unconjugated bile acids and trypsin in more neutral pH settings. Evidence of the involvement of bile and its constituents in humans has been less conclusive; however, the advent of better technology to detect bile reflux is beginning to clarify the role of these constituents. Human studies show that the reflux of bile parallels acid reflux and increases with the severity of gastroesophageal reflux disease, being most marked in BE. However, recent ex vivo studies suggest that pulses of acid reflux may be more important than bile salts in the development of dysplasia or adenocarcinoma in Barrett's epithelium. Nevertheless, antireflux surgery and aggressive acid suppression with proton pump inhibitors will decrease both acid and bile refluxes, and eliminate the synergism between these two duodenogastric constituents.     

Barrett's esophagus

Barrett's esophagus is an acquired condition resulting from severe esophageal mucosal injury. It still remains unclear why some patients with gastroesophageal reflux disease develop Barrett's esophagus whereas others do not. The diagnosis of Barrett's esophagus is established if the squamocolumnar junction is displaced proximal to the gastroesophageal junction and if intestinal metaplasia is detected by biopsy. Despite this seemingly simple definition, diagnostic inconsistencies remain a problem, especially in distinguishing short segment Barrett's esophagus from intestinal metaplasia of the gastric cardia. Barrett's esophagus would be of little importance were it not for its well-recognized association with adenocarcinoma of the esophagus. The incidence of esophageal adenocarcinoma continues to increase and the 5-year survival rate for this cancer remains dismal. However, cancer risk for a given patient with Barrett's esophagus is lower than previously estimated. Current strategies for improved survival in patients with esophageal adenocarcinoma focus on cancer detection at an early and potentially curable stage. This can be accomplished either by screening more patients for Barrett's esophagus or with endoscopic surveillance of patients with known Barrett's esophagus. Current screening and surveillance strategies are inherently expensive and inefficient. New techniques to improve the efficiency of cancer surveillance are evolving rapidly and hold the promise to change clinical practice in the future. Treatment options include aggressive acid suppression, antireflux surgery, chemoprevention, and ablation therapy, but there is still no clear consensus on the optimal treatment for these patients.     

Peroral endoscopic myotomy outcomes: Efficacy and gastroesophageal reflux disease

Achalasia is a well-defined neuromuscular disorder of esophageal swallowing function characterized by a nonrelaxing lower esophageal sphincter (LES) and aperistalsis of the esophageal body. Peroral endoscopic myotomy (POEM) is a flexible endoscopic approach to perform a selective circular myotomy of the distal esophagus and proximal stomach. More than a thousand cases have been performed worldwide. Most early reports on POEM focus on its feasibility and safety. Emerging long-term series have reported excellent subjective and objective outcomes of dysphagia relief for achalasia. With increasing experience, centers are expanding indications to end-stage achalasia and nonachalasia neuromuscular disorders such as diffuse esophageal spasm and nonrelaxing LES with hypertensive esophageal body contractions. The postoperative gastroesophageal reflux post-POEM is an issue that requires close objective follow-up, as the correlation of subjective reflux symptoms and objective testing in this setting is poor. Few series have indeed reported on equivalent excellent outcomes post-POEM as compared with a laparoscopic myotomy. This early experience with POEM has demonstrated the validity of this new technique in the management of benign disorders of esophageal swallowing. Refinements in technique and decreases in gastroesophageal reflux disease may make this procedure even more desirable, and potentially the first-line therapy in the management of spastic disorders of the esophagus.     

Reoperations after esophagomyotomy in esophageal motility disorders

Out of 96 patients with the diagnosis of primary esophageal motor disorders and treated by esophagomyotomy, a group of 9 patients is reported in whom reoperation was necessary because of persistence or worsening of the previous symptoms (8 patients) or persistent reflux esophagitis (one patient). Clinical and laboratory examinations together with the operative findings allowed classification of these patients: incomplete myotomy proximally (4 patients) or distally (one patient), fibrotic scar at the site of previous myotomy (2 patients), persistence of intact muscle fibers (one patient) and reflux esophagitis for lack of an antireflux intervention during myotomy. Treatment consisted of completing myotomy proximally or distally, resection of the fibrous tissue and an antireflux operation when indicated. Clinical results were excellent in 6 patients (66.6%), fair in 2 patients (22.2%) and bad in one case (11.1%). Fair or bad results were seen in patients with total absence of motor response to deglutition. After operation there was disappearance of vigorous contractions in the esophagus, as shown by manometry and recovery of esophageal peristalsis in another patient. We conclude that in order to improve the results of the surgical treatment of motor esophageal disorders it is essential to correctly classify the type of disorder present by means of manometry and to add a partial funduplication to ensure absence of reflux without dysphagia.