Esophageal Function Tests and Successful Esophageal Surgery: Introduction

Esophageal Function Tests and Successful Esophageal Surgery: Introduction

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he esophagus, unlike other gastrointestinal organs, has no digestive, absorptive, or endocrine functions. Its sole purpose is rapid, unidirectional transit of food from the hypopharynx to the stomach. This rudimentary task is performed by an exquisitely uncomplicated system of a muscle pump subtended by two valves. Despite this simplicity, surgical repair of the esophagus and restoration of its function are both demanding and difficult. In part, these are the results of limited options for esophageal repair. The lower esophageal sphincter may be fortified and returned to the abdomen. The esophageal body and the upper and lower esophageal sphincters may be myotomized. Diverticulectomy may be a necessary addition to myotomy. If esophageal function is not salvageable, resection and replacement is the only surgical choice. This restricted surgical repertoire limits restoration of esophageal function. This, plus the irreversibility of any surgical attempt to restore esophageal function, makes accurate preoperative assessment of esophageal function essential. A barium esophagram provides an excellent assessment and overview of esophageal function. It is a superb starting point for an examination of suspected abnormalities of esophageal function. All too often, however, this crucial examination is incompletely- performed or reported, and vital information is lost. Total examination, including Copyright © 2001 ~v W.E. Saunders Campa,!), do;:l 0.1 053/st[5.200 1.27648

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the video portion, should be available to review with a gastroenterology radiologist before repair. Esophageal manometry allows quantification of resting pressures, relaxation of esophageal sphincters, and assessment of peristalsis of the esophageal body. It is the signature test of esophageal function. Its performance is mandatory before any esophageal repair. It permits customization of surgery by matching the repaired element to the existing nonrepaired esophageal components. A large percentage of esophageal surgery is directed towards correction of a dysfunctional lower esophageal sphincter. The best predictor of a successful repair of an incompetent lower esophageal sphincter is 24-hour pH monitoring. This provides accurate and precise measurement of reflux and determination of the pattern of reflux. This examination is the gatekeeper for fundoplication. A complete evaluation of esophageal function, including upper gastrointestinal endoscopy is necessary to plan esophageal surgery. The ability to then repair the esophagus, however, is limited. If the initial surgery is unsuccessful, future attempts are progressively less likely to produce a satisfactory result. Therefore, effective esophageal repair requires a complete assessment of esophageal function, a well-planned surgery based on these physiological studies, and technical precision in esophageal reconstruction. Thomas W. Rice, MD Guest Editor

Seminars ill Thoracic and Cardiovascular Surgery, Vol 13, No 3 (july), 2001: p 200