Abstract
Purpose
Detailed understanding of the functional anatomy of the lower esophageal sphincter (LES) is germane to successful surgical treatment of esophageal disorders. However, a comprehensive concept of the structure–function relationship of the LES is currently lacking.
Methods
We reviewed published anatomic evidence, medical imaging, and impedance manometry data sets and developed a novel functional concept of the LES.
Results
Morphologic evidence accumulated over the past three decades indicates that the LES is an anatomic structure that differs markedly from typical ring sphincters of the gastrointestinal tract (e.g., upper esophageal sphincter or anal sphincters). Recent impedance manometry investigations shed new light on the functional anatomy of the LES. These data corroborate a concept of this sphincter as a double-layer, twisted stretch sphincter. This sphincter requires tissue tension for optimal function. Retightening of the longitudinal stretch of the esophagus provides an effective therapy if this tension is lost, e.g., for patients with hiatal hernias. Paralysis of the muscle fibers of this sphincter system results in functional obstruction, and this explains the pathophysiology of “achalasia”.
Conclusions
Based on available data, we propose a novel concept that better explains the structure–function relationship of the LES. Improved knowledge of the biomechanical factors of esophageal disorders can be expected to advance surgical treatment for these diseases.
Similar content being viewed by others
References
Stelzner F (1998) Surgery of the visceral sphincter systems. Thieme, Stuttgart
Stelzner F, Von Mallek D, Schneider B (2004) Stretching esophagopexy on the gastric wall is the best treatment for gastroesophageal reflux disease. Zentralbl Chir 129:345–349
Stelzner F, Lierse W (1968) The angiomuscular dilation closing of the terminal esophagus. Langenbecks Arch Chir 321(1):35–64
Stelzner F, Roedel R, Biersack HJ, Jager OE, von Mallek D (2004) Demonstration of increased natural spontaneous activity of cranioesophageal and laryngeal muscles by PET-CT. Chirurg 75:291–297
Feneis H (1946) About the function of oblique musculature. Aerztl Wschr 1:251–260
Stelzner F (2006) Embryology and anatomy of the organ of continence. In: Lange J, Moelle B, Girona J (eds) Surgical proctology. Springer, Heidelberg
Altschuler SM, Boyle JT, Nixon TE, Pack AI, Cohen S (1985) Simultaneous reflex inhibition of lower esophageal sphincter and crural diaphragm in cats. Am J Physiol 249:G586–G591
Imdahl H, Von Eiff AW, Jesdinsky H (1962) Manometric and electromanographic studies of hiatal hernias. Langenbecks Arch 301:799–803
Monges H, Salducci J, Naudy B (1978) Dissociation between the electrical activity of the diaphragmatic dome and crura muscular fibers during esophageal distension, vomiting and eructation. An electromyographic study in the dog. J Physiol Paris 74:541–554
De Troyer A, Sampson M, Sigrist S, Macklem PT (1982) Action of costal and crural parts of the diaphragm on the rib cage in dog. J Appl Physiol 53:30–39
Domingues GR, Winograd R, Lemme EM, Lammert F, Silny J, Matern S et al (2005) Characteristics of oesophageal bolus transport in patients with mild oesophagitis. Eur J Gastroenterol Hepatol 17:323–332
Dreuw B, Fass J, Buchin P, Silny J, Rau G, Schumpelick V (1998) Combined pH measurement and multiple impedance variation assessments—validation of a new technique for detection of non-acid reflux in the esophagus. Langenbecks Arch Chir Suppl Kongressbd 115:1143–1145
Nguyen HN, Domingues GR, Lammert F (2006) Technological insights: combined impedance manometry for esophageal motility testing-current results and further implications. World J Gastroenterol 12:6266–6273
Stelzner F, Lierse W, Mannfrahs F (1986) The hypoganglionic and aganglionic high pressure zone of the anterior esophagus (the esophageal opening) and its special blood supply (angiomuscular sphincter closure). Langenbecks Arch Chir 367:187–196
Ellis FH, Olsen AM (1969) Achalasia of the esophagus. Major problems in clinical surgery. Saunders, London
Nguyen HN, Domingues GR, Winograd R, Koppitz P, Lammert F, Silny J et al (2003) Impedance characteristics of normal oesophageal motor function. Eur J Gastroenterol Hepatol 15:773–780
Stelzner F (2004) Re-tightening of the double stretch sphincter of the esophagus—an anatomic concept for the treatment of reflux esophagitis. Minim Invasive Chir 13:175–181
Stelzner F, Kaufmann P (2004) The re-tightened stretch sphincter of the esophagus—the muscularis mucosae layer is a second stretch sphincter. Visceralchirurgie 39:296–302
Massey BT, Simuncak C, LeCapitaine-Dana NJ, Pudur S (2006) Transient lower esophageal sphincter relaxations do not result from passive opening of the cardia by gastric distention. Gastroenterology 130:89–95
Nguyen HN, Domingues GR, Winograd R, Lammert F, Silny J, Matern S (2004) Impedance characteristics of esophageal motor function in achalasia. Dis Esophagus 17:44–50
Adams CW, Brain RH, Trounce JR (1976) Ganglion cells in achalasia of the cardia. Virchows Arch A Pathol Anat Histol 372:75–79
Goldblum JR, Whyte RI, Orringer MB, Appelman HD (1994) Achalasia. A morphologic study of 42 resected specimens. Am J Surg Pathol 18:327–337
Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–495, discussion 495-497
Watson A, Spychal RT, Brown MG, Peck N, Callander N (1995) Laparoscopic ‘physiological’ antireflux procedure: preliminary results of a prospective symptomatic and objective study. Br J Surg 82:651–656
Watson DI, Jamieson GG, Pike GK, Davies N, Richardson M, Devitt PG (1999) Prospective randomized double-blind trial between laparoscopic Nissen fundoplication and anterior partial fundoplication. Br J Surg 86:123–130
Wykypiel H, Gadenstaetter M, Klaus A, Klingler P, Wetscher GJ (2005) Nissen or partial posterior fundoplication: which antireflux procedure has a lower rate of side effects? Langenbecks Arch Surg 390:141–147
Siewert JR, Stein HJ (1997) Fundoplication—the global crusade. In: Laffer U, Siewert JR, Stein HJ (eds) 100 years Rudolf Nissen. Schwabe, Basel, pp 113–124
Boutelier P, Jonsell G (1982) An alternative fundoplicative maneuver for gastroesophageal reflux. Am J Surg 143:260–264
Thor KB, Silander T (1989) A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 210:719–724
Franzen T, Bostrom J, Tibbling Grahn L, Johansson K (1999) Prospective study of symptoms and gastro-oesophageal reflux 10 years after posterior partial fundoplication. Br J Surg 86:956–960
Duda M (1984) Surgical treatment of functional disorders of the esophagus. Palacky, Olumouc, Czechoslovakia
Conflicts of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Stelzner, F., Stelzner, M. Manometry data support a novel concept of the lower esophageal sphincter system. Langenbecks Arch Surg 395, 1083–1091 (2010). https://doi.org/10.1007/s00423-010-0662-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00423-010-0662-x