Surgery

The choice between surgery and dilatation as the primary mode of treatment is often determined by local referral patterns. When gastroenterologists with an interest in the esophagus are the first line of referral, dilatation is most often performed. When patients are referred directly to sur geons, surgery is more likely to be performed as the initial therapeutic intervention. Which group dominates in a particular locale appears to be passed down through generations of physicians and is based more on tradition than evidence. Studies suggest a good to excellent result from surgical myotomy in 70 to 90% of patients. Overall, a 10% better response rate with surgery over dilatation is supported in the literature. However, outcomes may be more operator dependent with myotomy than with dilatation.

This better response rate for myotomy, however, comes with some baggage. Although some surgeons claim excellent results without postoperative reflux problems, others have found clinically significant gastroesophageal reflux occurs in a large proportion of patients. For that reason, myotomy is often combined with an antireflux procedure. However, in the face of absent peristalsis, fundoplication can interpose an obstructive element, therefore, at least conceptually, counteracting the primary goal of surgery. For this reason, when antireflux surgery is included, a partial fundoplication is usually preferred. Myotomy can be performed through either a thoracic or abdominal approach. It is my impression that abdominal surgeons tend to favor the addition of an antireflux component, whereas thoracic surgeons do not.

Aside from reflux, postoperative problems include early or late recurrence of obstructive symptoms. Early recurrence may be due to inadequate myotomy or obstruction by the wrap. Late recurrence may also be due to an inadequate myotomy, but is more likely to occur from a reflux-induced inflammation and stricture formation. It is often difficult to distinguish between these alternative causes.

Recently there has been a trend towards thoracoscopic or laparoscopic approach to myotomy. The benefits of minimally invasive surgery are primarily in terms of faster postoperative recovery and less patient discomfort. Although these benefits are real and often sufficient to make a patient favor a surgical option that they might otherwise refuse, it is unlikely that minimally invasive surgery is in fact superior to its open variant in terms of long term results. Nonetheless, the introduction of laparoscopic and thora-coscopic myotomy has created a more balanced playing field, in which surgery and dilatation are increasingly seen as valid initial treatment options.

Constipation Prescription

Constipation Prescription

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