Patients with unexplained chest pain or dysphagia are often referred for esophageal manometric studies to further investigate their symptoms. Four main manometric abnormalities have been described: achalasia, diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, and hypocontracting esophagus. With the exception of achalasia, treatments are of limited benefit and the natural history of these conditions is largely unknown. We sent questionnaires to patients who were investigated at least three years before our study began. They repeated a DeMeester symptom questionnaire that they had completed at the time of their initial study. Questionnaires were sent to 137 patients with diffuse esophageal spasm, "nutcracker" (hypercontracting) esophagus, or hypocontracting esophagus. We also sent questionnaires to 57 patients with dysphagia or chest pain who had had normal esophageal manometry and pH studies. These patients acted as symptomatic controls. Responses were compared using the Wilcoxon signed ranks test. Seventy-two (53%) patients with diffuse esophageal spasm, "nutcracker" esophagus, or hypocontracting esophagus replied. An additional 8 (6%) patients died. Symptom scores in all three conditions had improved significantly over time (p < or = 0.01 for each condition, Wilcoxon signed ranks test). Patients with dysphagia or chest pain but normal esophageal studies had not improved. The significance of diffuse esophageal spasm, "nutcracker" esophagus, and hypocontracting esophagus found at esophageal manometry remains uncertain. Although treatment is often ineffective, these conditions typically run a benign course. Patients can be reassured that their symptoms are likely to improve with time.

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Guidelines are less clinical excellence than hindranceEditor-We have two comments on the paper by Bloor et al on the impact of NICE guidance on laparoscopic surgery for inguinal hernias. 1 Firstly, the authors say that guidance from the National Institute for Clinical Excellence (NICE) on laparoscopic hernia repair had no impact on practice and that the rate of laparoscopic repair has not changed much. Although the rate of laparoscopic repair has not changed, NICE guidance has an impact on practice as it stopped the normal progression in laparoscopic hernia repair. Without the guidance the number of laparoscopic repairs would be much larger now.Secondly, surgeons who were already doing laparoscopic repairs have not stopped doing so, and morbidity has not increased, which means that the NICE guidance was not correct. The European Hernia Trials Group found that the incidence of recurrence in laparoscopic and Lichtenstein repairs was similar (2.3% and 2.9%).2 A recent study from Germany, including 8050 patients, showed that recurrence rate for transabdominal preperitoneal hernia repair is only 0.4%. 3Although the difference is minimal, the true cost of laparoscopic hernia repair is lower. Late adapters may never changeEditor-With respect to the impact of NICE guidance on laparoscopic surgery for inguinal hernias by Bloor et al, 1 any change process, regardless of the quality of evidence backing it up, is enthusiastically embraced by only a minority of up to 20%, the "early adapters." The remainder follow suit at a varying pace, leaving a rump of "late adapters," who may never change if given the choice. Expecting change after only a year would seem to be naively optimistic.Furthermore, laparoscopic hernia repair, by the authors' own admission, is a comparatively uncommon procedure, accounting for less than one in 20 of all operations. Despite a minute increase, the number of laparoscopic hernia repairs carried out after the introduction of the guidelines is still low.The surgeons responsible may be postulated to consist of two groups: the middle to late adapters and those who have made a clinical judgment that, given the circumstances, laparoscopic repair is the treatment of choice for specific patients.Short of a total ban on the procedure, I can think of no measure by which a notable change in practice could have been achieved in a very short timescale in this particular case. NICE evaluation has data shortage and short analysis periodEditor-The article by Bloor et al on the impact of NICE guidance for inguinal hernia repair opens an essential debate. 1 To be confident in the results, however, it would have been useful to know the procedure and diagnosis codes used by the authors in their analysis. This would allow local trusts to undertake a similar analysis to test the impact locally.Furthermore, how confident are the authors in the data provided within the hospital episode database? If data coding and auditing is poor then using this as a data source for clinical governance purposes may be compromised.Quite ...