Endoscopic surgical treatment of primary oesophageal motility disorders

Achalasia, nutcracker oesophagus and diffuse oesophageal spasm are primary oesophageal motility disorders whose treatment has been substantially impacted by the advent and development of minimally invasive surgery. Although several studies had shown that oesophageal myotomy was effective in the treatment of several of these disorders, particularly in the more advanced stages, many of the patients who could have benefited from an operation were instead with medications or balloon dilation, sometimes despite repeated failures of this form of therapy. To a certain extent, this reflected patient and physicians' concerns with the post-operative discomfort and the long recovery time inevitably associated with the performance of a thoracotomy or laparotomy. Today, however, we and others have shown that minimally invasive techniques allow an operation to be performed with the same excellent results provided by open surgery, but with a shorter hospital stay, minimal post-operative discomfort, and faster return to work. We performed our first thoracoscopic myotomy for achalasia in January of 1991, initially using a technique developed by Dr. Cuschieri, which we modified as we gained experience. Subsequently, we extended the same technique to the treatment of diffuse oesophageal spasm and nutcracker oesophagus. This report describes our experience at the University of California at San Francisco and the University of Washington in Seattle for the diagnostic and therapeutic approach to patients with primary oesophageal motility disorders.