Therapy of noncardiac chest pain: is there a role for surgery?

Esophageal distention, motor abnormalities, or exposure of the esophageal mucosa to acidic gastric juice can cause chest pain indistinguishable from that of myocardial ischemia in patients with and without coronary artery disease. In these situations the exact cause of the symptom needs to be established prior to any surgical therapy. An antireflux procedure relieves chest pain in patients with increased esophageal acid exposure more reliably than medical therapy. The best results are obtained in patients in whom a direct correlation of the symptom with reflux episodes can be documented on 24-hour esophageal pH monitoring. Ambulatory 24-hour esophageal motility monitoring shows that esophageal motor disorders are a less frequent cause of noncardiac chest pain than suggested by standard manometry or provocation tests. Furthermore, chest pain episodes in patients with esophageal motor abnormalities are not associated with single contractions of excessively high amplitude or duration. Rather, the symptom appears to be triggered by an increased frequency of simultaneous, multipeaked, and repetitive motor activity. In appropriately selected patients with chest pain and dysphagia secondary to an esophageal motor abnormality, a long esophageal myotomy eliminates the ability of the esophagus to produce these contractions, reduces or eliminates dysphagia, and decreases the frequency and severity of chest pain episodes.