Myenteric plexus in spastic motility disorders

Previous studies have often revealed an absence or reduction of ganglia in Auerbach's plexus in many patients with achalasia, which has been postulated to be related to the elevated lower esophageal sphincter pressure in these patients. We undertook a prospective study to determine whether microscopic changes were present in the myenteric plexus of patients with hypertensive lower esophageal sphincter, nutcracker esophagus, and diffuse esophageal spasm and if there was a correlation with lower esophageal sphincter pressure. Nine patients (3 men and 6 women; ages 49 to 72 years, mean 58 years) underwent a laparoscopic esophagomyotomy with fundoplication for symptomatic spastic motility disorder. A 10 mm x 5 nim segment of esophageal muscle was removed from the border of the myotomy incision, fixed in formalin, and examined under light microscopy for the presence or absence of ganglia and inflammation. Correlation between the presence of ganglia and lower esophageal sphincter pressure was tested by Pearson's bivariant correlation. Manometry revealed three patients with hypertensive lower esophageal sphincter, four patients with nutcracker esophagus, and two patients with diffuse esophageal spasm. All three patients with a hypertensive lower esophageal sphincter revealed an absence of ganglia, whereas the six patients with nutcracker esophagus and diffuse esophageal spasm exhibited ganglia despite an elevated lower esophageal sphincter pressure in four. Hypertensive lower esophageal sphincter resembled achalasia in its absence of ganglia in Auerbach's plexus, whereas nutcracker esophagus and diffuse esophageal spasm exhibited ganglia. There was no significant correlation in our series between the presence of ganglia and an elevated lower esophageal sphincter pressure in spastic motility disorders.