Surgical management of esophageal motility disturbances

During the past few decades, knowledge regarding normal and abnormal esophageal behavior has greatly increased because of the introduction of sophisticated techniques of studying esophageal function. As a result, the normal motility patterns of the esophagus are now well known, and conditions characterized by disturbances of esophageal motility can be readily recognized and therapy can be designed along more physiologic lines than heretofore.Motility disturbances of the esophagus can be classified as those involved with the upper esophageal sphincter and those involving the body of the esophagus and lower esophageal sphincter. Cricopharyngeal myotomy has played an increasing role in the management of abnormalities of function of the upper esophageal sphincter, particularly in patients with hypertension of the upper esophageal sphincter or incoordination of the upper esophageal sphincter as seen in pharyngoesophageal diverticulum. Esophagomyotomy has also found a useful place in the management of symptomatic patients with esophageal achalasia, in whom I believe it is the primary treatment of choice. Results of a properly performed myotomy suggest that an ancillary antireflux maneuver is not necessary. Although diffuse spasm of the esophagus and hypertensive sphincter represent different forms of esophageal motility disorders characterized by hypermotility rather than hypomotility, in properly selected patients a long esophagomyotomy has been useful in relieving the disabling symptoms of pain and dysphagia exhibited by most of these persons.Hypotension of the lower esophageal sphincter is now recognized as an underlying mechanism responsible for gastroesophageal reflux in a variety of disease states. Thus reflux and its debilitating sequence of ulcerative esophagitis and stricture formation should now be viewed as a physiologic abnormality rather than a strictly anatomic abnormality such as may occur in the presence of diaphragmatic hernia. Treatment is primarily medical and is designed to minimize the occasions of reflux and its effects by reducing gastric acids. Only in a small percentage of patients is surgical treatment in the form of an antireflux procedure required.