Eypasch E P, DeMeester T R, Klingman R R, Stein H J
University of Southern California School of Medicine, Department of Surgery, Los Angeles 90033-4612.
J Thorac Cardiovasc Surg. 1992 Oct;104(4):859-68; discussion 868-9.
The physiologic abnormalities and management of patients with diffuse esophageal spasm are controversial. We evaluated the symptomatic and functional results of surgical therapy in 19 patients with diffuse esophageal spasm who were incapacitated with dysphagia and chest pain and unresponsive to conservative management. A long esophageal myotomy with an antireflux procedure was performed in 15 patients, and four patients with multiple previous esophageal procedures had an esophagectomy. Eleven patients had increased esophageal exposure to gastric juice on preoperative 24-hour esophageal pH monitoring. The severity of dysphagia, chest pain, regurgitation, and heartburn was scored on a scale of 0 to 3 before and a mean of 24 months (range 8 months to 13 years) after the operation. After myotomy, each of these symptoms and the overall symptom score improved significantly (p < 0.01). The improvement in the symptom scores in the patients who had esophagectomy were comparable with the improvement after myotomy. On self-assessment, 90% of the patients would have the operation again if again faced with the decision. Standard and ambulatory 24-hour manometry showed a significant reduction in the amplitude of the esophageal body contractions, a decrease in the frequency of simultaneous contractions, and the elimination of multi-peaked waves after the myotomy. Despite the addition of an antireflux procedure, lower esophageal sphincter pressure, overall length, and abdominal length were reduced markedly after the myotomy. This was associated with persistent or emerging heartburn or regurgitation in four patients. These data indicate that a long esophageal myotomy is a valid treatment alternative in appropriately selected patients with diffuse esophageal spasm. Esophagectomy and colon interposition is the procedure of choice in patients with multiple previously failed myotomies.
弥漫性食管痉挛患者的生理异常及治疗存在争议。我们评估了19例弥漫性食管痉挛患者手术治疗的症状及功能结果，这些患者因吞咽困难和胸痛而丧失能力，且对保守治疗无反应。15例患者接受了长段食管肌层切开术并加抗反流手术，4例曾多次接受食管手术的患者接受了食管切除术。11例患者术前24小时食管pH监测显示食管对胃液的暴露增加。在手术前及术后平均24个月（范围8个月至13年），对吞咽困难、胸痛、反流和烧心的严重程度按0至3分进行评分。肌层切开术后，这些症状及总体症状评分均显著改善（p<0.01）。接受食管切除术患者的症状评分改善情况与肌层切开术后相当。自我评估显示，90%的患者如果再次面临抉择，仍会选择再次接受手术。标准及动态24小时食管测压显示，肌层切开术后食管体部收缩幅度显著降低，同步收缩频率减少，多峰波消失。尽管加行了抗反流手术，但肌层切开术后食管下括约肌压力、总长度及腹段长度均明显降低。这与4例患者持续存在或新出现的烧心或反流有关。这些数据表明，对于适当选择的弥漫性食管痉挛患者，长段食管肌层切开术是一种有效的治疗选择。对于多次肌层切开术失败的患者，食管切除术及结肠代食管术是首选术式。
