The oesophago-gastric sphincter after cardiomyotomy.

Surgical operations performed for the relief of achalasia of the cardia are liable to be followed by gastro-oesophageal reflux. Although this complication occurred much more frequently after earlier procedures such as cardioplasty or oesophago-gastric anastomosis than after Heller's cardiomyotomy (Barrett and Franklin, 1949; Ripley, Olsen, and Kirklin, 1952; Brewer, Barnes, and Redo, 1956), it is nevertheless encountered in a minority of patients after the latter operation. Estimates of the incidence of gastro-oesophageal reflux after cardiomyotomy vary considerably. Hawthorne, Frobese, and Nemir (1956) found this to be present in four of 35 patients who had undergone cardiomyotomy, and Acheson and Hadley (1958) reported heartburn in 13 of 22 patients after this operation. Gertz (1952), however, did not encounter reflux in 11 patients subjected to cardiomyotomy, and Gammie, Jennings, and Richardson (1958) state that "cardiomyotomy by itself does not lead to incompetence of the cardia or to gastrooesophageal reflux." It is now well established that the normal oesophago-gastric sphincter can be demonstrated by manometric methods as a localized zone at the oesophago-gastric junction in which intraluminal pressure is raised (Fyke, Code, and Schlegel, 1956; Botha, Astley, and Carre, 1957; Atkinson, Edwards, Honour, and Rowlands, 1957a). In this study a similar manometric technique has been used to assess the functional state of the oesophago-gastric sphincter after cardiomyotomy. The purpose was to determine whether the development of gastro-oesophageal reflux after this operation depended upon the extent of the disruption of the sphincter. By this means it was hoped to provide additional information about the importance of this sphincter in maintaining the competence of the cardia.