Surgical intervention for esophageal dysmotility

Esophageal motility disorders encompass a number of distinct disease processes that share the common end result of peristaltic derangement and impaired relaxation of the lower esophageal sphincter. This article outlines the surgical and endoscopic interventions appropriate for individuals with achalasia and other motor disorders of the esophagus. Conceptualizing the esophageal motility disorders as primarily nonspastic (types I and II achalasia and esophagogastric junction outflow obstruction) or spastic (type III achalasia, jackhammer esophagus, and distal esophageal spasm) can help inform the choice of initial and subsequent treatments. Pneumatic dilatation and laparoscopic Heller myotomy have roughly equivalent success in relieving symptoms of esophageal outflow obstruction, with a more durable effect seen with the surgical approach as well as decreased incidence of gastroesophageal reflux with the addition of a partial fundoplication. In the management of spastic motility disorders, surgical myotomy has provided significantly better outcomes than pneumatic dilation, potentially attributable to division of spastic musculature proximal to the esophagogastric junction. Similarly, BoTox delivered to the esophageal body has recently been shown to relieve symptoms in distal esophageal spasm. Peroral endoscopic myotomy (POEM) is a novel therapy that allows for the creation of a surgical myotomy, without the need for skin incisions. The antegrade, endolumenal approach used in POEM has also allowed for personalized tailoring of the proximal myotomy of the esophageal body in the treatment of spastic motility disorders. POEM has a growing body of longer-term follow-up that suggest initial concerns surrounding increased incidence of gastroesophageal reflux may not be realized.