Operation for motor dysfunction of the esophagus

Myenteric plexus of the hind-gut: developmental abnormalities in humans and experimental studies

Intraluminal pressure studies on patients with congenital aganglionosis showed that the aganglionic rectum contracted in an uncoordinated manner and failed to relax. Histochemical assessment of the innervation helped to explain the variable severity of the symptoms in this condition. It is concluded that (1) absence of ganglia prevents normal coordinated peristalsis and creates an obstructive element; (2) absence of reflex relaxation adds to the obstruction; (3) the degree of uncoordinated motor activity in distal aganglionic bowel probably relates to the number of cholinesterase-positive nerves in the circular muscle and adds another variable obstructive element; and (4) deficient innervation of distal ganglionic bowel probably creates a poor propulsive force and so accentuates more distal obstructive factors. Neurohistochemical and functional studies in the anorectum of cats reveal a somewhat different innervation pattern from that in humans but show that sphincteric tone is mainly due to alpha-adrenergic neural activity. Reflex relaxation of the internal anal sphincter is a complex function in which inhibitory responses override motor responses, and it involves an important non-adrenergic non-cholinergic component. The role of cholinergic nerves in the sphincter remains uncertain. Neurohistochemical assessment of full thickness biopsy specimens of rectal muscle from patients with disabling constipation shows that developmental neuronal dysplasias of the hind-gut may be divided into three main categories: (1) aganglionosis (Hirschsprung's disease), (2) hypoganglionosis and (3) hyperganglionosis, and that the different neuronal elements may be affected to differing degrees in individuals within each group. Resection of the aganglionic bowel is required in congenital aganglionosis but the combined diagnostic-therapeutic procedure of anorectal myotomy has been found beneficial in patients with hypoganglionosis.

Diffuse esophageal spasm

The purpose of this article is to review the clinical features, pathophysiology, diagnosis, and management of patients with diffuse esophageal spasm (DES). The PubMed database was searched with a focus on recent publications, using keywords "DES," plus "epidemiology," "prevalence," "diagnosis," "pathogenesis," "calcium channel blocker," "nitrates," "botulinum toxin," "antidepressants," "dilation," and "myotomy." The reference lists of papers identified in the initial PubMed search were reviewed for further relevant publications.

Peppermint oil improves the manometric findings in diffuse esophageal spasm

BACKGROUND

Diffuse esophageal spasm (DES) is an uncommon condition that results in simultaneous esophageal contractions. Current medical treatment of DES is frequently unsatisfactory. We hypothesized that, as a smooth muscle relaxant, peppermint oil may improve the manometric findings in DES.

STUDY

Eight consecutive patients with chest pain or dysphagia and who were found to have DES were enrolled during their diagnostic esophageal manometry. An eight-channel perfusion manometry system was used. Lower esophageal sphincter pressure and contractions of the esophageal body after 10 wet swallows were assessed before and 10 minutes after the ingestion of a solution containing five drops of peppermint oil in 10 mL of water. Each swallow was assessed for duration (seconds), amplitude (mm Hg), and proportion of simultaneous and multiphasic esophageal contractions.

RESULTS

Lower esophageal sphincter pressures and contractile pressures and durations in both the upper and lower esophagus were no different before and after the peppermint oil. Peppermint oil completely eliminated simultaneous esophageal contractions in all patients (p < 0.01). The number of multiphasic, spontaneous, and missed contractions also improved. Because normal esophageal contractions are characteristically uniform in appearance, variability of esophageal contractions was compared before and after treatment. The variability of amplitude improved from 33.4 +/- 36.7 to 24.9 +/- 11.0 mm Hg (p < 0.05) after the peppermint oil. The variability for duration improved from 2.02 +/- 1.80 to 1.36 +/- 0.72 seconds (p < 0.01). Two of the eight patients had chest pain that resolved after the peppermint oil.

CONCLUSIONS

This data demonstrates that peppermint oil improves the manometric features of DES.

Antireflux operations in patients with scleroderma

Fourteen patients with scleroderma underwent antireflux operations (10 short Nissen, 2 Collis-Nissen, 1 Collis-Belsey, and 1 vagotomy and antrectomy with Roux-en-Y). Esophageal function was assessed preoperatively and postoperatively with a follow-up range of 8 to 181 months (mean, 65 months). Reflux symptoms were relieved in 10 of the 14 patients (p < 0.01), as shown by a decrease in their 24-hour acid exposure of from 15% to 7.5% (p < 0.05). However, the lower esophageal sphincter pressure gradient created by the operations did not increase significantly (3.7 +/- 3.4 mm Hg to 5.5 +/- 3.5 mm Hg). The esophageal acid exposure decreased sufficiently to promote some alleviation of the esophagitis. Radiologic signs of stenosis regressed in 6 of 7 patients. Postoperative endoscopic assessment revealed complete or partial healing of erosions seen preoperatively in 6 of the 7 patients so studied, and healing of all ulcers in 3 patients. Twelve patients continued to have columnar metaplasia. Manometric studies disclosed no significant changes in propulsion and contractility. Distal esophageal resting pressures rose significantly from 6.2 to 9.4 mm Hg (p < 0.05 mm Hg), suggestive of stasis. Radionuclide transit studies, however, showed no significant decrease in the esophageal emptying capacity after operation. It is concluded that conventional antireflux operations in patients with scleroderma can palliate reflux damage without jeopardizing esophageal function.

Achalasia of the cardia: long-term results of oesophagomyotomy and posterior partial fundoplication

Forty-eight patients with achalasia of the cardia were treated by Heller's myotomy with a posterior fundoplication of approximately 270 degrees, suturing the gastric fundus to the edges of the myotomy. The mean(s.d.) postoperative follow-up period was 5.4(2.8) years. The clinical results were good to excellent in 44 cases (92 per cent) and fair in four cases (8 per cent) (two with residual dysphagia and two with gastrooesophageal reflux). Barium studies showed a decrease in oesophageal diameter and disappearance of distal narrowing but normal oesophageal emptying did not occur. Postoperative manometric studies (29 patients) revealed a significant decrease in lower oesophageal sphincter pressure and a significant increase in the length of the infradiaphragmatic segment. In the oesophageal body a recovery of peristaltic waves in the proximal third was seen in ten of the patients (34 per cent). Twenty-four-hour pH monitoring showed pathological reflux in only three of 25 patients studied, and one of these was asymptomatic. This technique is effective, improving oesophageal symptoms and controlling long-term reflux.

Surgical management of primary motor disorders of the esophagus

Primary motor disorders of the esophagus can be managed surgically with excellent results. Between the years 1972 and 1983, 40 patients were managed by us. The patients ranged in age from 14 to 79 years (mean 36.3 years). Thirty-six patients were managed primarily by the authors and 4 patients secondarily. The distribution of the hypodynamic states were achalasia in 29 patients, vigorous achalasia in 5 patients, and diffuse spasm in 1 patient, whereas the hyperdynamic states were squeeze syndrome in 2 patients, super-squeeze syndrome in 1 patient, and hypertensive lower esophageal sphincter in 2 patients. Of the 36 patients in hypodynamic states, 27 had a modified Heller myotomy and reconstruction of the gastroesophageal junction with a Belsey fundoplication and 9 had only a modified Heller myotomy. There was only one patient with reflux esophagitis. It occurred after myotomy and Belsey fundoplication for a hypertensive lower esophageal sphincter and hiatus hernia. Four patients were managed secondarily for complicated recurrent problems, one with a Belsey fundoplication and three with a jejunal interposition graft. We recommend myotomy, with or without a Belsey fundoplication, for management of primary motor disorders and avoidance of total Nissen fundoplication and a lengthening Collis gastroplasty.

Selective application of fundoplication in achalasia

Although esophagomyotomy alone may effectively relieve dysphagia in patients with achalasia, utilization of a complementary fundoplication procedure should be considered for selected patients. Fundoplication is a sensible addition to myotomy in circumstances that suggest high risk for the development of reflux esophagitis. Also, in complicated achalasia, relief of esophageal obstruction by simple myotomy may not be achieved safely. Identification of those pathological features associated with achalasia that merit consideration of fundoplication should improve operative results and reduce morbidity. This paper examines the application of a complementary fundoplication procedure in the operative management of 21 patients with achalasia over a ten-year period.

Reflux control following myotomy in diffuse esophageal spasm

Sixty-five patients with diffuse esophageal spasm (DES) were investigated by history, radiology, manometry, and endoscopy prior to surgical management. At operation they underwent extended myotomy to the apex of the chest, including the high-pressure zone; in addition, all had hiatal hernia repair. Four types of repair were used: the Belsey procedure, partial fundoplication gastroplasty, total fundoplication gastroplasty, and the Nissen procedure. With the Belsey or the partial fundoplication, there was a high incidence of continued reflux. With the total fundoplication procedure, there was no reflux; however, 6 patients had minor dysphagia and 1 had major dysphagia. With myotomy and a standard Nissen fundoplication, 13 patients were asymptomatic and 2 had minor dysphagia; none had major residual symptoms.

Effects of total fundoplication on function of the esophagus after myotomy for achalasia

Twelve patients underwent distal esophageal myotomy for achalasia. After denuding the esophageal mucosa over 50 percent of its circumference, a short (2 cm) total fundoplication was performed over a size 56 mercury bougie. Clinical evaluation showed marked symptomatic improvement. Obstructive symptoms are minimal, and no reflux symptoms were noted. Manometric documentation showed a significant decrease in resting esophageal and lower esophageal sphincter pressure. Contraction pressure was also lowered, and peristalsis returned in 36 percent of the waves in the proximal esophagus. Radiologic and scanning documentation revealed slow emptying without evidence of significant reflux. Endoscopic evaluation revealed no esophagitis after 19 months' follow-up.