Is a good clinical result satisfactory if there is no equivalent manometric improvement ?

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

Esophageal myotomy is mechanistic surgery, i.e., the operation is performed to improve the function of the gastrointestinal tract and alleviate symptoms by altering the structure or arrangement of its moving parts. In this regard, myotomy is different from extirpational surgery in which the diseased organ is removed and the consequences of its loss are the side effects of the operation. The success of extirpational surgery is measured in survival. In contrast, the success of a mechanistic procedure like esophageal myotomy depends on both relief from symptoms and verification that the deficiency in esophageal function has been corrected or improved by the operation.

Measuring the success of esophageal myotomy purely on the symptomatic improvement of the patients or on the information derived from a roentgenographic barium swallow is not an adequate evaluation of the procedure. The postoperative

presence of what appears to be esophageal symptoms may be due to another disease entity that has been misdiagnosed ; likewise, the absence of symptoms may reflect a temporary placebo effect of the operation.

To assess the success of the procedure, long-term relief of symptoms and functional improvement need to be documented.