Postvagotomy Dysphagia

To the Editor.—  The recent article on postvagotomy dysphagia by Stephen Carter, MD, deserves further comment.As Dr Carter noted, trauma to the lower esophagus associated with searching for tiny vagal fibers can produce edema, hematoma, and, finally, fibrosis. Others have reported that the incidence of this complication varies with the degree of manipulation of the esophagus by the surgeon.¹ I believe this is the most common reason, if not the only one, for postvagotomy dysphagia.Dysphagia secondary to vagal denervation (so-called postvagotomy achalasia) is a concept that was popularized in the last 20 years, because the "bird-beaking" of the distal esophagus on radiographic scans resembled the picture seen with classic achalasia or "cardiospasm." However, the diagnosis of achalasia currently rests on the demonstration by esophageal manometry of certain features: failure of relaxation of the lower esophageal sphincter pressure after swallowing and either absent or nonperistaltic esophageal contractions.I