The anti-reflux mechanism after cardiomyotomy

Area of Science:

• Gastroenterology
• Surgical Research

Background:

• Achalasia is a motility disorder characterized by increased lower esophageal sphincter pressure.
• Cardiomyotomy is a surgical procedure to treat achalasia by cutting the esophageal muscle.
• The anti-reflux mechanism after cardiomyotomy is not fully understood.

Purpose of the Study:

• To investigate the cause of the high-pressure zone in the esophagus after cardiomyotomy.
• To determine the role of the hiatus versus residual sphincter fibers in the anti-reflux mechanism.

Main Methods:

• Radiographic assessment of barium reflux in patients post-cardiomyotomy.
• Perfusion manometry to evaluate the pressure zone at the esophagogastric junction.
• Assessing the response of the pressure zone to increased abdominal pressure.

Main Results:

• Barium reflux was induced in a minority of patients (18/83) after cardiomyotomy.
• Mucosal herniation through the myotomy was observed in most patients.
• A persistent high-pressure zone was detected in 22/24 patients, which increased with abdominal pressure.
• This incremental response was also observed in a patient with a hiatal hernia and myotomy.

Conclusions:

• The persistent high-pressure zone after cardiomyotomy is likely due to the esophageal hiatus.
• The hiatus, not residual sphincter fibers, is likely responsible for the pressure response to abdominal increases.
• The hiatal mechanism, rather than sphincter fibers, is the more probable anti-reflux mechanism post-cardiomyotomy.