Intraoperative esophageal manometry in surgical treatment of achalasia: a reappraisal.

BACKGROUND/AIMS: Intraoperative Esophageal Manometry is used during surgery for gastroesophageal reflux disease to obtain a better lower esophageal sphincter pressure, or during the Heller procedure for achalasia to verify the myotomy. The effectiveness of this manometry is not explicit. MATERIAL AND METHODS: From 1977 to 1987, 58 patients underwent surgery for achalasia at our Institution. A transabdominal Heller's myotomy and a modified Dor's anterior fundoplication were performed in all cases. During the operation, Lower Esophageal Sphincter Pressure was measured in 38 patients (A group) to verify the completeness of the càr-diomyotomy; the fundoplication-induced pressure increase was also recorded. Twenty patients (B group) underwent surgery without intraoperative manometry. Forty-six patients (30 of A group and 16 of B group) were followed up for 24 to 120 months (median 68 months) by means of a clinical questionnaire, barium meal, manometry and 24-hour esophageal pH monitoring. RESULTS: In 21 cases, intraoperative manometry showed the completeness of the myotomy at the first record, while in the remaining 17 it revealed the persistence of a High Pressure Zone; in these, a more accurate incision of the muscle layers on the anterior surface of the esophagus was subsequently performed up to a complete abolition of the HPZ. Long-term results were excellent or good in 27 (90%) patients of A group and in 9 (56%) patients of B group. Dysphagia and gastro-esophageal reflux were the commonest findings in patients with poor results. CONCLUSION: The usefulness of intraoperative manometry in the surgical treatment of achalasia is emphasized and some technical details are reported.