Effects of laparoscopic myotomy on the esophageal motility pattern of esophageal achalasia as measured by high-resolution manometry

Abstract Aim Ulcerating CMV associated esophagitis in an immuncompetent patient has not been described before. This case report highlights diagnostic pitfalls in differentiating achalasia from pseudo achalasia. Background & Methods A 41-year-old man presented to the high resolution manometry lab with progressive retrosternal dysphagia and regurgitation. Endoscopy revealed a dilated esophagus with a passable stenosis of the esophagogastric junction. Between 27 to 39 cm a deep 3 x 12 cm ulcer reaching the lamina muscularis was detected. Biopsies were taken and processed to the institute for pathology and microbiology. A barium swallow revealed typical features of achalasia. A dilated hypomotile esophagus and a beak sign were seen. Histopathology described a deep ulcer with a mixed inflammatory infiltration without any signs for malignancy. The virology finally revealed a strong positivity for CMV in PCR. Therefor the diagnosis of CMV esophagitis was made. Reasons for an immunodeficiency (HIV, Trypanosoma pallidum etc.) could be excluded. After endoscopic placement of a probe, high resolution manometry was performed. It showed a disturbed EGJ relaxation, an enhanced residual pressure (IRP) and panesophageal pressurizations in almost every swallow. These are typical features of Type II Achalasia (Chicago Classification v 3.0). Results The patient received antiviral therapy (Ganciclovir) for 2 months. Only a moderate symptom relief was achieved. Endoscopic reevaluation showed a complete remission of the huge esophageal ulcer. There was no esophageal scar or other reason for EGJ obstruction. CMV was no longer detected. A second high resolution manometry confirmed again a Type II Achalasia. The patient underwent laparoscopic myotomy an 180° degree fundoplication. 6 months after the intervention the patient is well and has a complete remission of his symptoms. Conclusion Although ulcerating CMV esophagitis may be a cause of pseudoachalasia, in this case for the first time primary achalasia is described to be the reason for ulcerating CMV esophagitis.

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PS01.005: HIGH-RESOLUTION MANOMETRY GUIDING SURGICAL PROCEDURE FOR TREATMENT OF ACHALASIA OF THE ESOPHAGUS. LONG-TERM RESULTS OF A PROSPECTIVE STUDY

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.005 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 51-51

Author(s):

Tania Triantafyllou ◽

Georgia Doulami ◽

Charalampos Theodoropoulos ◽

Georgios Zografos ◽

Dimitrios Theodorou

Keyword(s):

High Resolution ◽

Prospective Study ◽

Conflicts Of Interest ◽

Long Term Results ◽

Type I ◽

Laparoscopic Myotomy ◽

Term Outcome ◽

Long Term Outcome ◽

High Resolution Manometry

Abstract Background Laparoscopic myotomy and fundoplication for the treatment of achalasia presents with 90% success rate. The intraoperative use of manometry during surgery has been previously introduced to improve the outcome. Recently, we presented our pilot study proposing the use of the HRM during surgery. The aim of this study is to evaluate the long-term outcome of the intraoperative use of High-Resolution Manometry (HRM) in achalasia patients. Methods In this prospective study, consecutive achalasia patients underwent laparoscopic myotomy and fundoplication along with real-time use of HRM. Eckardt scores (ES) and HRM results were collected before and after surgery. Results Twenty-three achalasia patients (22% Type I, 57% Type II, 22% Type III, according to Chicago Classification v3.0) with a mean age 48 years underwent calibrated and uneventful myotomy and fundoplication. Eleven myotomies were further extended, while sixteen fundoplications were intraoperatively modified, according to manometric findings. During postoperative follow-up, mean resting and residual pressures of the LES were significantly decreased after surgery (16,1 vs. 41,9, P = 0 and 9 vs. 28,7, P = 0, respectively). The ES was also diminished (1 vs. 7, P = 0). Conclusion The intraoperative use of HRM during laparoscopic myotomy and fundoplication for the treatment of achalasia of the esophagus is a safe, promising and efficient approach aiming to individualize both myotomy and fundoplication for each achalasia patient. Disclosure All authors have declared no conflicts of interest.

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P173 HIGH-RESOLUTION MANOMETRIC FINDINGS AFTER MAGNETIC SPHINCTER AUGMENTATION

Diseases of the Esophagus ◽

10.1093/dote/doz092.173 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Carlo Galdino Riva ◽

Stefano Siboni ◽

Veronica Lazzari ◽

Marco Sozzi ◽

Emanuele Asti ◽

...

Keyword(s):

High Resolution ◽

Esophageal Motility ◽

Symptom Relief ◽

Rank Test ◽

Barium Swallow ◽

Upper Gastrointestinal Endoscopy ◽

Magnetic Sphincter Augmentation ◽

Hrql Score ◽

High Resolution Manometry ◽

Ineffective Esophageal Motility

Abstract Aim The aim of this study was to evaluate esophageal motility before and after Magnetic Sphincter Augmentation (MSA) for medically refractory Gastro-Esophageal Reflux Disease (GERD). Background and Methods MSA (LINX® Reflux Management System) is intended for patients with chronic GERD with incomplete symptom relief from proton-pump inhibitors (PPI) and abnormal acid exposure. A prospectively collected database of patients who underwent MSA between 2007 and 2019 was queried. All patients who completed pre- and post-operative high-resolution manometry (HRM) were included in the study. Additional investigations included Health-Related Quality of Life (GERD-HRQL) questionnaire, Functional Outcome Swallowing Scale (FOSS), upper gastrointestinal endoscopy, barium swallow, and 24-96 hours pH-study. Data were analyzed using Wilcoxon signed rank test and McNemar test. Results Forty-five patients met the inclusion criteria. The median follow-up was 10 months (IQR 6). Compared to baseline, there was a statistically significant reduction in PPI use (p=0.000), rate of heartburn (p=0.000), regurgitation (p=0.008), and extra-esophageal symptoms (p=0.000). Only three (6.7%) patients required dietary changes. The GERD-HRQL score significantly improved (p=0.000). There was a significant increase in the Lower Esophageal Sphincter (LES) competency, including LES length (p=0.004) and Esophago-gastric Contractile Integral ((EGJ-CI) (p=0.000). A significant increase in integrated relaxation pressure (IRP) (p=0.000), mean Distal Contractile Integral (DCI) (p=0.008) and intrabolus pressure (p=0.000) was also found. Thirteen (28.9%) patients presented pre-operative Ineffective Esophageal Motility (IEM) and five of them resolved postoperatively. Two patients (4.4%) developed IEM after surgery: both had IRP and DCI values within normal limits, and one of them complained of dysphagia. However, the GERD-HRQL score recovered in both patients. Conclusion MSA was clinically effective in relieving both typical and atypical GERD symptoms. LES competency increased after MSA. EGJ outflow obstruction was uncommon and not associated with symptoms. Finally, ineffective esophageal motility may reverse to normal after MSA.

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