Long myotomy with antireflux repair for esophageal spastic disorders

Abstract

This report presents the long-term subjective and objective results of esophageal myotomy and fundoplication by thoracotomy in the treatment of esophageal spastic disorders. From 1977 to 1995, a total of 16 patients with esophageal spastic disorders were referred to our unit and underwent a myotomy with an added partial (n = 12) or total (n = 4) fundoplication. The median follow-up was 6 years. Assessments included clinical evaluation, esophagogram, radionuclide emptying, manometry, 24-hour pH studies, and endoscopy. From the global results, patients with pure spastic disorders (n = 8) were compared to patients with spastic disorders with an accompanying epiphrenic diverticulum (n = 8). There were no deaths, and morbidity was minimal. Preoperative symptoms were similar in all patients with spastic disorders. After surgery, the clinical outcome was significantly better in patients with spastic disorders in the presence of a diverticulum. Delays in esophageal emptying persisted after surgery. Patients with pure spastic disorders showed more diffuse functional abnormalities. Patients with a diverticulum had dysfunction mostly in the distal esophagus. Both groups showed signs of coordination and relaxation abnormalities in the lower esophageal sphincter. Myotomy with antireflux surgery resulted in decreased propulsion and contraction pressure. The resting pressure and relaxation at the level of the lower esophageal sphincter improved, but the coordination abnormalities remained. Failure resulted from either reflux complications (n = 1) or obstruction (n = 4). Patients with spastic disorders plus a diverticulum showed better clinical results and improved esophageal function after surgery when compared to patients with pure spastic disorders.