Pharyngo-oesophageal dysphagia: surgery based on clinical and manometric data

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Abstract
High or pharyngo-oesophageal dysphagia (PD) is defined as difficulty ininitiating the act of swallowing within 1s. It involves the mechanismscontrolling the tongue, pharynx and upper oesophageal sphincter (UOS) andis associated with a wide variety of local, neurologic and musculardisorders, and can also occur after surgery in the area and in response togastro-oesophageal reflux (GOR). Our study aims at defining the criteriafor surgery in PD and to evaluate the clinical results of such treatment.Twenty-three patients who underwent surgery were evaluated withpharyngo-oesophageal motility and ambulatory 24-hr pH-metry. The followingparameters were measured: 1) pharyngeal contraction amplitude, 2) duration,3) repetitive pharyngeal contractions, 4) UOS tone, 5) percentage of UOSrelaxation, 6) duration of relaxation, 7) UOS closing pressure, 8) UOSclosing duration, 9) co-ordination of UOS closing pressure and upperoesophageal (UO) contractions. Preoperative manometry showed a variety ofabnormalities in several of the parameters, such as prolonged pharyngealcontraction ("spasm"), unco- ordinated pharyngeal contractions and UOSrelaxation, low amplitude pharyngeal contractions, unco-ordinated UOSclosing tone and UO contractions and hypotonic UO. Surgery was directed atthe specific abnormality in each patient taking into consideration thepresence or absence of GOR. Seventeen patients (74%) had excellent results.Three other patients (13%), who had improved swallowing but who continuedto have GOR complicated by some oesophageal dysmotility, oesophagitis andan oesophageal web, underwent subsequent anti-reflux surgery with relief ofsymptoms. In conclusion, pharyngo-oesophageal motility measurement ismandatory in PD, especially when a diverticulum is absent. Cricopharyngealmyotomy with or without diverticulectomy as indicated produces excellentresults. Associated oesophageal problems have to be dealt withappropriately.

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