Experimentation as an aid in management of esophageal disorders

Abstract

Simultaneous pressure and pH studies have been performed in over 200 subjects, with a wide variety of esophageal disorders, and in twenty normal subjects. From these studies the pH and pressure profiles have been clearly depicted in both health and disease. Combined studies with two pressure tubes in the esophagus have deomonstrated the progression of swallow waves in the normal subject, and the failure of the progression of swallow waves into the terminal esophagus in the patient with advanced esophagitis. Combined studies with a pressure tube placed in the esophagus and one in the stomach has allowed a measurement of the gradients across the gastroesophageal junction. The influence of these gradients in producing reflux indicates that the conventional maneuvers, such as the Mueller and Valsalva which are employed by the roentgenologist in an effort to produce reflux, often close the esophagus tightly and prevent reflux in spite of a large pressure gradient across the gastroesophageal junction. The most potent maneuvers that produce the highest pressure gradients across the junction have been inspiratory sniffing and simulated hiccoughs, or singultus. These have produced pressure gradients as high as 200 cm. of water across the sphincter and are the best means of producing reflux. In a final analysis, however, the most frequent condition under which we were able to demonstrate reflux has been the supine position with the patient relaxed. These studies have been standardized to the point where they are an integral part of the evaluation of the patient with esophageal disease. They are particularly helpful in detecting the early stages of esophagitis, achalasia, diffuse spasm, scleroderma, as well as other benign esophageal disorders. They have been useful in delineating the underlying mechanisms of esophageal disease. Pre- and postoperative studies on unusual conditions such as Schatzki's ring and high gastric diverticula have been illuminating. With these technics the surgeon has an objective means of determining the presence of early derangement of the esophagus preoperatively and thereby is in a better position to avoid many of the poor results in surgery which stem from an inaccurate diagnosis. In addition, postoperative studies and posttreatment studies serve to define objectively the effect of therapy. Our studies indicate that simple closure of the hiatus is an inadequate operation for reflux esophagitis. These studies also point out that reconstructing sutures should be applied in conjunction with the Heller operation in order to prevent reflux following this procedure. These studies have been helpful in differentiating the pain of angina pectoris from that of reflux esophagitis and in delineating reflux in those subjects in whom no demonstrable hernia or reflux could be demonstrated by conventional roentgenographic technics. Further studies to define the influence of vagotomy and other ancillary procedures employed in esophageal disease are in progress.