Physiologic assessment and surgical management of diffuse esophageal spasm

The physiologic abnormalities and management of patients with diffuse esophageal spasm are controversial. We evaluated the symptomatic and functional results of surgical therapy in 19 patients with diffuse esophageal spasm who were incapacitated with dysphagia and chest pain and unresponsive to conservative management. A long esophageal myotomy with an antireflux procedure was performed in 15 patients, and four patients with multiple previous esophageal procedures had an esophagectomy. Eleven patients had increased esophageal exposure to gastric juice on preoperative 24-hour esophageal pH monitoring. The severity of dysphagia, chest pain, regurgitation, and heartburn was scored on a scale of 0 to 3 before and a mean of 24 months (range 8 months to 13 years) after the operation. After myotomy, each of these symptoms and the overall symptom score improved significantly (p < 0.01). The improvement in the symptom scores in the patients who had esophagectomy were comparable with the improvement after myotomy. On self-assessment, 90% of the patients would have the operation again if again faced with the decision. Standard and ambulatory 24-hour manometry showed a significant reduction in the amplitude of the esophageal body contractions, a decrease in the frequency of simultaneous contractions, and the elimination of multi-peaked waves after the myotomy. Despite the addition of an antireflux procedure, lower esophageal sphincter pressure, overall length, and abdominal length were reduced markedly after the myotomy. This was associated with persistent or emerging heartburn or regurgitation in four patients. These data indicate that a long esophageal myotomy is a valid treatment alternative in appropriately selected patients with diffuse esophageal spasm. Esophagectomy and colon interposition is the procedure of choice in patients with multiple previously failed myotomies.