Esophagomyotomy for Esophageal Achalasia and Diffuse Esophageal Spasm

Abstract

In esophageal achalasia the body of the esophagus is unable to produce organized peristaltic contractions, and the lower esophageal sphincter fails to relax following the act of swallowing. This combination of events results in partial obstruction. The esophagus dilates. The patient suffers from dysphagia, regurgitation, tracheal aspiration, and pneumonitis in advanced cases. Long-term relief from the symptoms of achalasia requires either hydrostatic dilatation of the lower esophagus or an esophagomyotomy. Both procedures result in interrupting the continuity of the circular muscle surrounding the distal esophagus. Sanderson, Ellis, and Olsen report that hydrostatic dilatation has been successful in relieving symptoms in 815 of their cases, of which 3.2% required emergency surgery for esophageal perforation. There were no deaths. On the other hand, Ellis, Kiser, Schlegel, Earlam, and others (1967) feel that surgical esophagomyotomy is the treatment of choice for esophageal achalasia. They experienced one death from malignant hyperthermia in 269 operations. There was only a 35 incidence of symptomatic reflux esophagitis. An additional 3% of cases experienced poor results in the form of either persistent or recurrent symptoms of dysphagia not related to gastroesophageal reflux. A majority of the patients having poor results from esophagomyotomy had previously under-gone unsuccessful treatment by hydrostatic dilatation or surgery. Using a similar technique of esophagomyotomy, Okike, Payne, and Newfeld also noted only a 3% incidence of postoperative reflux esophagitis in a study of 200 operations for achalasia done at the Mayo Clinic from 1967 to 1975. These authors report good or excellent results in 90% of their patients.