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Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique.The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%.Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up.Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.

A 67-year-old man complained of recurrent retrosternal pain for 3 - 5 minutes as the only symptom for 3 - 4 years. Only when dysphagia occurred in the course of the disease was a gastroenterologist consulted.The diagnosis of diffuse esophageal spasm was confirmed by esophageal manometry and radiology. Upper gastrointestinal endoscopy revealed no further pathological findings.100 units of botulinum toxin were injected in 10 divided doses, into the tubular esophagus, 1 cm apart, beginning at the z-line of the gastroesophageal junction, deeply into the muscular coat of the posterior part of the esophageal wall. This achieved improvement of symptoms as well as esophageal transit time measured by scintigraphy. The symptomatic benefit has now lasted for several months.The treatment of patients with diffuse esophageal spasm with botulinum toxin is a promising therapeutic option, which can be safely performed in such patients. But this regime needs evaluation in controlled prospective clinical studies.

A 55-year-old woman had for 5 years been suffering from severe burning thoracic pain. She had typical risk factors for cardiovascular disease, namely hypertension, chronic smoking, obesity and hypercholesterolaemia. She had been hospitalized several times for suspected myocardial infarction, but coronary heart disease had been excluded by cardiac examination, including angiocardiography. The only contributory admission finding was epigastric pain on pressure.Gastroscopy revealed a non-erosive duodenitis and chronic antral gastritis. The cardia was tightly closed and there were no signs of reflux oesophagitis. Manometry in the oesophagus showed frequent simultaneous contractions and marked increase in pressure amplitude, predominantly in the distal segment, indicating diffuse oesophageal spasms.Drug treatment with calcium channel blockers gave only brief relief from the thoracic pain. But longitudinal oesophageal myotomy via thoracoscopy brought about complete pain relief, which has now persisted for 3 years.Thoracoscopic longitudinal oesophageal myotomy can provide a therapeutic alternative in patients with oesophageal spasms when drug therapy and pneumatic oesophageal dilatation have failed.

A 75-year-old man was admitted for oesophageal manometry because of dysphagia for the past 2 years and retrosternal burning sensation unrelated to exercise. His general condition was appropriate for his age.An oesophagogram showed corkscrew-like deformation of a diffuse oesophageal spasm. The first, but incomplete, manometry recorded clearly propulsive contractions with markedly raised and prolonged pressure, as in "nutcracker oesophagus". The lower oesophageal sphincter could not be demonstrated initially. Subsequent pH measurements provided no evidence for increased gastrooesophageal reflux.After the first manometry conservative treatment was initiated with molsidomine, nifedipine and nitrospray sublingual, but the dysphagia was not significantly improved. A second manometry was performed before a planned surgical exploration. Placing of the catheter was again difficult and mild resistance experienced. Endoscopy revealed only minimal, presumably superficial, mucosal lesions. 2 days later bilateral pleural effusions together with mediastinitis occurred. Conservative treatment was continued until finally a distal oesophageal perforation was demonstrated. At surgery the perforation was seen and a oesophagectomy with gastric pull-through and intrathoracic anastomosis performed. However, the patient died of septic multi-organ failure.Oesophageal manometry is a safe but invasive method with few complications for measuring oesophageal motility. Although this has not previously been reported, oesophageal perforation with mediastinitis may end fatally, if the particular circumstances are unfavourable. In addition to special anatomical features, type and state of the manometric catheter may present a risk factor.

Felson and Lessure 1964 (1) described varicosities involving the upper third of the esophagus in patients without portal hypertension. Several etiological factors causing these "downhill" varices, e.g. bronchogenic carcinoma, retrosternal thyroid adenoma or mediastinal fibrosis, have been described. Since September 1989 ectatic esophageal veins or "downhill" varices were diagnosed in nine patients with dysphagia and/or non cardiac chest pain. Intrathoracic masses as a possible cause of "downhill" varices could not be diagnosed in any of these patients. Endoscopy of the upper gastro-intestinal tract revealed spiral esophageal contractions as a potential sign of a esophageal motor disorder in seven patients. By means of esophageal manometry "nutcracker"-esophagus was seen in two patients and diffuse esophageal spasm in three patients. On the basis of these findings primary esophageal motor disorders should be considered as a possible cause of ectatic veins in the proximal esophagus and "downhill" varices.

Since the pharynx and the esophagus are a functional unit, functional radiodiagnosis has to be directed at pharyngo-esophageal interaction. Among our collective of 73 patients suffering from achalasia or diffuse esophageal spasm, we were able to recognize a substantially increased incidence of morphological or functional pharyngeal disorders by means of cineradiography. The functional alterations in particular were often not revealed by conventional fluoroscopy. High-speed cineradiography, with its high temporal and spatial resolution, turned out to be a valuable tool in analysis of the origin of pharyngeal dysphagia. Manometry correlated very well with the radiologic findings in tubular esophagus, but proved unreliable in the detection of alterations of the upper esophageal sphincter region, because of problems inherent in the method. Furthermore, membranous stenosis (webs), lateral or dorsal diverticula, and asymmetry of the pharynx were observed strikingly often.