Endoscopic oesophageal myotomy for specific motility disorders and non-cardiac chest pain

The management of oesophageal motility disorders has been unsatisfactory due to the lack of effective pharmacological treatment. Endoscopic surgical myotomy offers an effective long-term therapy without the disadvantages of a thoracotomy. After characterization by oesophageal manometry 12 patients with achalasia and 23 patients with non-cardiac chest pain were considered suitable for myotomy. For achalasia, the laparoscopic approach was preferred to the thoracoscopic route. Fundoplication was not performed unless a hiatus hernia was present or as a buttress protection following suture of an iatrogenic perforation of the oesophageal mucosa. For patients with non-cardiac chest pain a thoracoscopic long myotomy was performed from the left side with the patient operated on in the postero-lateral position. Three perforations (all sutured endoscopically) were encountered: two during cardiomyotomy, one during long myotomy. Complete or substantial relief of chest pain was encountered in 18 patients, with five patients having no relief of their pain. Our experience indicates that long myotomy is successful but longer term follow-up is required to assess its therapeutic role.