Pharyngo-oesophageal dysphagia: surgery based on clinical and manometric data

High or pharyngo-oesophageal dysphagia (PD) is defined as difficulty in initiating the act of swallowing within 1s. It involves the mechanisms controlling the tongue, pharynx and upper oesophageal sphincter (UOS) and is associated with a wide variety of local, neurologic and muscular disorders, and can also occur after surgery in the area and in response to gastro-oesophageal reflux (GOR). Our study aims at defining the criteria for surgery in PD and to evaluate the clinical results of such treatment. Twenty-three patients who underwent surgery were evaluated with pharyngo-oesophageal motility and ambulatory 24-hr pH-metry. The following parameters were measured: 1) pharyngeal contraction amplitude, 2) duration, 3) repetitive pharyngeal contractions, 4) UOS tone, 5) percentage of UOS relaxation, 6) duration of relaxation, 7) UOS closing pressure, 8) UOS closing duration, 9) co-ordination of UOS closing pressure and upper oesophageal (UO) contractions. Preoperative manometry showed a variety of abnormalities in several of the parameters, such as prolonged pharyngeal contraction ("spasm"), unco-ordinated pharyngeal contractions and UOS relaxation, low amplitude pharyngeal contractions, unco-ordinated UOS closing tone and UO contractions and hypotonic UO. Surgery was directed at the specific abnormality in each patient taking into consideration the presence or absence of GOR. Seventeen patients (74%) had excellent results. Three other patients (13%), who had improved swallowing but who continued to have GOR complicated by some oesophageal dysmotility, oesophagitis and an oesophageal web, underwent subsequent anti-reflux surgery with relief of symptoms. In conclusion, pharyngo-oesophageal motility measurement is mandatory in PD, especially when a diverticulum is absent. Cricopharyngeal myotomy with or without diverticulectomy as indicated produces excellent results. Associated oesophageal problems have to be dealt with appropriately.