Motility Disorders

Motility disorders are usually classified as either achalasia or diffuse esoph-

Fig 17.6. Transthoracic Belsey Mark IV: A double-telescoping procedure of the esophagus into the stomach as a 270° wrap.

ageal spasm. Achalasia can be defined manometrically as failure of the lower esophageal sphincter to relax and lack of peristalsis of the proximal esophagus (Fig. 17.7). The treatment of achalasia is pneumatic dilation or a Heller esophagomyotomy. Diet modification and drugs are generally ineffective. Pneumatic dilation has an initial success rate in the range of 80%; however subsequently only less than 50% have long-term good results. Therefore in general we feel it should only be done for poor risk patients. Esophagomyotomy is probably the treatment of choice.

In a Heller esophagomyotomy, a lateral thoracotomy is performed in the 7th or 8th intercostal space. The muscular layer is taken down to the mucosa which is exposed and this is taken down 1 cm onto the stomach. One must dissect a plane between the mucosa and muscular layers lest the muscular layer reapproximates. The dissection is carried down to the junction of the esophagus with the stomach where the longitudinal submucosal venous plexus becomes the transverse venous plexus along the stomach. There is no need for an anti-reflux procedure since reflux only occurs in 3%, although some groups advocate a concomitant antireflux procedure with an esophagomyotomy. If recurrence of achalasia occurs after Heller esophagomyotomy, then another Heller esophagomyotomy is performed with more extensive dissection between the mucosal and muscular layers.

For diffuse esophageal spasm, pain is much more pronounced and the patients

rarely complain primarily of dysphagia alone. An upper GI may reveal narrowing and pseudodiverticulosis. Initial medical management consists of nitrates and calcium channel blockers; however these only work in about 50% of patients. Failure of these modalities requires a Heller esophagomyotomy but the proximal extent of the myotomy is longer compared to that for the treatment for achalasia. The level depends on preoperative esophageal motility studies which reveal the proximal extent of the esophageal spasm. If the lower esophageal sphincter is found to be normal manometrically, then the myotomy can stop short of the lower esoph-ageal sphincter. It should be noted that surgical treatment for spasm using esophagomyotomy is less effective than for achalasia.

Suggested Reading

1. Mathisen DJ, Grillo HC, Hilgenberg AD, Moncure AC, Wilkins EW Jr. Transthoracic esophagogastrectomy: A safe approach to carcinoma of the esophagus. Ann Thoracic Surg 1988; 45:137-143.

2. Ellis FH Jr, Gibb SP, Watkins E Jr. Esophagogastrectomy: A safe, widely applicable, and expeditious form of palliation for patients with carcinoma of the esophagus and cardia. Ann Surg 1983; 198:531-540.

3. Orringer MB. Transhiatal esophagectomy without thoracotomy for carcinoma of the thoracic esophagus. Ann Surg 1984; 200:282-288.

4. Katlic M, Grillo HC. Carcinoma of the esophagus. In: Choi NC, Grillo HC eds. Thoracic oncology. New York: Raven Press, 1983: 279.

5. Bare AE, Belsey RHR. The treatment of sliding hiatus hernia and reflux esoph-agitis by the Mark IV technique. Surgery 1967; 62:396-404.

6. Skinner DB, Belsey RHR. Surgical management of esophageal reflux and hiatus hernia. J Thorac Cardiovasc Surg 1967; 53:33-54.

7. Orringer MB. Surgical treatment of esophageal strictures resulting from gastroe-sophageal reflux. In: Stipa S, Belsey RHR, Moraldi A eds. Medical and surgical problems of the esophagus. New York: Academic Press, 1987: 165.

8. Ellis FH Jr, Crozier RE, Watkins E Jr. Operation for esophageal achalasia: Results of esophagomyotomy without an antireflux operation. J Thorac Cardiovasc Surg 1984; 88:344-351.

9. Pac M et al. Transhiatal vs. transthoracic esophagectomy for esophageal cancer. J Thorac Cardiovasc Surg 1993; 106:205.

10. Moon MR et al. Transhiatal and transthoracic esophagectomy for adenocarci-noma of the esophagus. Arch Surg 1992; 127:951.

11. Ellis FH et al. Esophagectomy for carcinoma of the esophagus and cardia: A comparison of findings and results after standard resection in three consecutive eight-year intervals with improved surgical criteria. J Thorac Cardiovasc Surg 1997; 113:836.

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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