Intraoperative Study on the Relationship Between the Lower Esophageal Sphincter Pressure and the Muscular Components of the Gastro-Esophageal Junction in Achalasic Patients

Abstract

In achalasic patients, 45% of the LES resting tone is maintained by the gastric side anatomical component of the GE junction. The range of variability of the gastric component of the LES is wide. This information should be taken into account when performing extramucosal myotomy as therapy for esophageal achalasia.

Operative manometry and endoscopy during laparoscopic Heller myotomy

“…Mattioli et al also used operative manometry to demonstrate the significance of the gastric component of the LES (the clasp and sling fibers of the collar of Helvetiius at the cardia) in the high-pressure zone of achalasic patients. In their 32 patients, mean LES pressure decreased by ∼20 mmHg after myotomy above the EGJ, and it decreased an additional 10 mmHg after the myotomy was continued below the EGJ onto the gastric cardia [10]. These results are comparable to our observations, in which the mean change in LES pressure immediately following completion of the myotomy, both above and below the EGJ, was 28 mmHg.…”

“…This technique also permits ready identification of the squamocolumnar junction (SCJ). Operative esophageal manometry, on the other hand, yielding a more functional assessment of the myotomy, has been used rather infrequently during open procedures [2,7,8,10] and even less often while performing laparoscopic Heller myotomy [4].…”

Mechanisms controlling function in the clasp and sling regions of porcine lower oesophageal sphincter

“…Patients with achalasia have a hypertensive and nonrelaxing LOS, and greatly increased tone in the sling region 22,30 . The most common neuronal abnormality in achalasia is an imbalance between excitatory and inhibitory EMNs in the myenteric plexus.…”

Recent Trends in the Management of Achalasia

“…Mattioli et al intraoperatively measured internal pressure to study the optimal incision length and extent in Heller myotomy. 24) They reported that a myotomy with a cut length of 2 cm on the gastric side maintained a LES pressure of 45%. They concluded that a 2-cm incision made distally to the gastroesophageal junction, after making a proximal incision of 5 to 6 cm, played the most important role in decreasing the final LES pressure after the Heller myotomy.…”