What is the success rate with surgical therapy ?

H.J. Stein, T.R. DeMeester (Omaha)

The results of surgical therapy for diffuse esophageal spasm have improved in parallel with the improved selection of patients provided by manometry.

Previous published series report results varying between 40 and 92 p. cent symptomatic improvement (table 1), but interpretation of these data is difficult due to the small numbers involved in each series and the varying criteria used to document the presence of the disease [1].

Table 1. Summary of results of surgical myotomy for diffuse esophageal spasm

					Symptomatic results
			No. of				Follow-up
	Reference	Year	patients	Procedure	Good Poor		period
	Ellis et al. [2]	1964	40	Myotomy	31 (77%)	9 (23 %)	1-6.5 yr
	Ferguson el al. [3]	1969	13	Myotomy	12 (92%)	1 (8%)	6 mo-12 yr
	Henderson et	1974	17	Myotomy, Belsey	12 (71%)	5 (29 %)	3-48 mo
	al. [4]					(2*)
			5	Myotomy,	5 (100%)	0
				gastroplasty, Belsey
	Flye and Sealy [5]	1975	11	Myotomy	11 (100%)	0	Not noted
	Leonardi et al. [6]	1977	11	Myotomy*	10 (91 %)	1 (9%)	1-6 yr
	Henderson	1987	20	Myotomy, Belsey	8 (40 %)	12 (60%)	8-11 yr
	and Ryder
			9	Myotomy,	6 (67 %)	3 (33 %)	7-10yr
				gastroplasty, Belsey
			19	Myotomy,	12 (63%)	7 (37%)	2-7 yr
				gastroplasty, Nissen
			15	Myotomy,	13 (87 %)	2 (13%)	1-3 yr
				short Nissen
	Total		160		120 (75 %)	40 (25 %)

* Myotomy sparing lower esophageal sphincter.

Of the last 47 patients with dysphagia and/or chest pain and the manometric pattern of diffuse esophageal spasm evaluated in our laboratory, 14 were treated surgically. Twelve patients had a myotomy and modified antireflux procedure, four of whom also had suspension of a mid esophageal diverticulum or resection of an epiphrenic diverticulum. Two patients had esophagectomy because of several previous unsuccessful esophageal operations.

Compared to prospectively scored preoperative symptoms (scale 0 to 3), dysphagia improved from an average of 2 to 0.6 and the severity and frequency of chest pain episodes improved from 2 to 0.9 postoperatively. Seven patients were

completely free of dysphagia and chest pain after a mean of 13 months (range three months to eight years) following the operation. On self assessment, 1/12 patients were cured, 10/12 reported an 80 p. cent improvement, and 1/12 was unchanged.

Effective palliation of symptoms therefore could be achieved in 92 p. cent of patients in our series.

References

1. DeMeester TR, (1982) Surgery for esophageal motor disorders. Ann Thorac Surg 34 : 225-229.

2. Ellis FH Jr, Olsen AM, Schlegel AF et al (1964) Surgical treatment of esophageal hypermotility disturbances. JAMA 188 : 862.

3. Ferguson TB, Woodbury JD, Roper CL (1969) Giant muscular hypertrophy of the esophagus. Ann Thorac Surg 8 : 209.

4. Henderson RD, Ho CS, Davidson JW (1974) Primary motor disorder of the esophagus (Diffuse spasm): Diagnosis and treatment. Ann Thorac Surg 18 : 327.

5. Flye MW, Sealy WC (1975) Diffuse spasm of the esophagus. Ann Thorac Surg 19 : 677.

6. Leonardi HK, Shea JA, Crozier RE et al (1977) Diffuse spasm of the esophagus. Clinical, manometric and surgical considerations. J Thorac Cardiovasc Surg 74: 736.

7. Henderson RD, Ryder D, Marryatt G (1987) Extended esophageal myotomy and short total fundoplication repair in diffuse esophageal spasm : Five-year review in 34 patients. Ann Thor Surg 43 : 25.