title: Surgical management of hypertensive lower esophageal sphincter with dysphagia or chest pain.
abstract: Hypertensive lower esophageal sphincter (LES) is an uncommon manometric abnormality found in patients with dysphagia and chest pain, and is sometimes associated with gastroesophageal reflux disease (GERD). Preventing reflux by performing a fundoplication raises concerns about inducing or increasing dysphagia. The role of myotomy in isolated hypertensive LES is also unclear. The aim of this study was to determine the outcome of surgical therapy for isolated hypertensive LES and for hypertensive LES associated with GERD. Sixteen patients (5 males and 11 females), ranging in age from 39 to 89 years, with hypertensive LES (>26 mm Hg; i.e., >95th percentile of our control population) who had surgical therapy between 1996 and 1999 were reviewed. Patients with a diagnosis of achalasia and diffuse esophageal spasm were excluded. All patients had dysphagia or chest pain. Eight of 16 patients had symptoms of GERD, four had a type III hiatal hernia, and four had isolated hypertensive LES pain. Patients with hypertensive LES and GERD or type III hiatal hernia had a Nissen fundoplication, and those with isolated hypertensive LES had a myotomy of the LES with partial fundoplication. Outcome was assessed as follows: excellent if the patient was asymptomatic; good if symptoms were present but no treatment was required; fair if symptoms were present and required treatment; and poor if symptoms were unimproved or worsened. All patients were contacted by telephone for symptom assessment at a median of 3.6 years (range 3 to 6.1 years) after surgery. Patients with hypertensive LES and GERD or type III hiatal hernia had significantly lower LES pressure than those with isolated hypertensive LES (29.9 vs. 47.4 mm Hg; P=0.013). Dysphagia and chest pain were relieved in all patients at long-term follow up. Outcome was excellent in 10 of 16, good in 3 of 16, and fair in 3 of 16. All patients but one were satisfied with their outcome. Patients with hypertensive LES are a heterogeneous group in regard to symptoms and etiology. Treatment of patients with hypertensive LES should be individualized. A Nissen fundoplication for hypertensive LES with GERD or type III hiatal hernia relieves dysphagia and chest pain suggesting reflux as an etiology. A myotomy with partial fundoplication for isolated hypertensive LES relieves dysphagia and chest pain suggesting a primary sphincter dysfunction.
authors.affiliation: Department of Surgery, University of Southern California, Los Angeles, California 90033, USA.
authors.forename: Anand P
authors.initials: AP
authors.lastname: Tamhankar
authors.forename: Gideon
authors.initials: G
authors.lastname: Almogy
authors.forename: Mustafa A
authors.initials: MA
authors.lastname: Arain
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Portale
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Hagen
authors.forename: Jeffrey H
authors.initials: JH
authors.lastname: Peters
authors.forename: Peter F
authors.initials: PF
authors.lastname: Crookes
authors.forename: Lelan F
authors.initials: LF
authors.lastname: Sillin
authors.forename: Steven R
authors.initials: SR
authors.lastname: DeMeester
authors.forename: Cedric G
authors.initials: CG
authors.lastname: Bremner
authors.forename: Tom R
authors.initials: TR
authors.lastname: DeMeester
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000209:etiology; D003680:Deglutition Disorders / Q000209:etiology; D013505:Digestive System Surgical Procedures / Q000379:methods; D004935:Esophageal Diseases / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D004943:Esophagogastric Junction / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000379:methods; D005764:Gastroesophageal Reflux / Q000150:complications / Q000601:surgery*; D006801:Humans; D008297:Male; D008365:Manometry / Q000379:methods; D008875:Middle Aged; D011312:Pressure / Q000009:adverse effects; D012189:Retrospective Studies; D016896:Treatment Outcome