Neuromuscular imbalance of the esophagus associated with hiatal hernia.

This report reemphasizes the association of hiatal hernia and neuromuscular disease of the esophagus. Thirty-eight patients out of a group of 130 studied by esophageal manometry had the combination of hiatal hernia and a neuromuscular problem of the esophagus ranging from severe hypoactivity to severe hyperactivity. One-third of the patients had no treatment, one-third bad hernia repair alone, and one-third had a hernia repair plus a long Heller myotomy. In this latter group, all of the patients had hyperactive esophageal responses ranging from relatively mild to severe spasm of the lower esophagus. Ten of 13 patients had complete amelioration of the dysphagia. In the patients not having a HeUer myotomy, the dy~phagia persisted. It has been concluded from thii study that all patients with a hiatal hernia and unexplained dysphagia should have intraesophageal pressure studies or cinefluoroscopy of the esophagus to evaluate esophageal function. The addition of a long myotomy to the hernia repair in those patients with hyperactive responses adds little risk to the procedure and has resulted in remission of the dysphagia in the majority of patients studied.