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Answer
Reading File
Finding Sources
Finding Sources
Reading File
Reading File
Answer: D) Heller's myotomy + Dor fundoplication
Diagnosis: Diffuse Esophageal Spasm (DES)
The clinical picture is classic:
- Chest pain + dysphagia for 8 months
- High-resolution manometry showing: massive, simultaneous, high-pressure contractions of the distal esophagus + absent peristalsis
This manometric pattern - simultaneous, high-amplitude contractions with absent normal peristalsis - defines Diffuse Esophageal Spasm.
Why NOT the other options?
| Option | Why Incorrect |
|---|---|
| A) Ramstedt's pyloromyotomy | This is for hypertrophic pyloric stenosis in infants - completely unrelated |
| B) Dohlman procedure | This is an endoscopic stapling procedure for Zenker's diverticulum |
| C) Nissen's fundoplication | This is for GERD / hiatal hernia - treats reflux, not spasm |
| D) Heller's myotomy + Dor fundoplication | CORRECT - surgical treatment for esophageal motility disorders |
Why Heller's Myotomy + Dor Fundoplication?
Heller's myotomy (long esophagomyotomy) divides the circular muscle fibers of the distal esophagus, relieving the high-pressure simultaneous contractions. It provides relief of dysphagia in up to 80% of highly selected DES patients.
Dor fundoplication (anterior partial wrap) is added to prevent post-operative GERD after the myotomy disrupts the lower esophageal sphincter mechanism.
This is the surgical answer when medical management (calcium channel blockers, anticholinergics, botox injections) has failed in DES.
- Maingot's Abdominal Operations confirms: "more recent reports of small series have shown good results for relief of dysphagia after esophageal myotomy in up to 80% of highly selected patients"
- Lee's Essential Otolaryngology: "Heller myotomy with or without fundoplication - 70% to 90% success rate" for esophageal motility disorders
The answer is D.
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