Heller Myomectomy for Distal Esophageal Spasm

Symptomatic distal esophageal spasm (formerly called diffuse esophageal spasm) is part of a spectrum of motility disorders characterized variously by nonpropulsive contractions and hyperdynamic contractions, sometimes in conjunction with elevated lower esophageal sphincter pressure. Symptoms are chest pain and sometimes dysphagia. Diagnosis is by barium swallow or manometry. Treatment is difficult but includes nitrates, calcium channel blockers, botulinum toxin injection, surgical or endoscopic myotomy, and antireflux therapy. Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Sometimes, distal esophageal spasm is asymptomatic and is found incidentally. When symptomatic, distal esophageal spasm typically causes substernal chest pain with dysphagia for both liquids and solids. Very hot or cold liquids may aggravate the pain. Over many years, this disorder rarely evolves into achalasia.Esophageal spasms can cause severe pain without dysphagia. This pain is often described as a substernal squeezing pain and may occur in association with exercise. Such pain may be similar to angina pectoris, and patients often present to the emergency department concerned they are having a heart attack. Esophageal spasms are often difficult to treat, and controlled studies of treatment methods are lacking. Oral calcium channel blockers may be useful. Anticholinergics, tricyclic antidepressants, nitroglycerin, and long-acting nitrates may also be tried but generally have limited success. Rarely, a trial of injecting botulinum toxin type A into the esophagus and/or lower esophageal sphincter is done.If medical management fails, a myotomy may be considered. A surgical or peroral endoscopic extended myotomy of the esophagus has been tried in severe cases.