P173 HIGH-RESOLUTION MANOMETRIC FINDINGS AFTER MAGNETIC SPHINCTER AUGMENTATION

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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P172 ESOPHAGEAL SUBMUCOSAL LIPOMA AND CONCOMITANT INEFFECTIVE MOTILITY: LAPAROSCOPIC TRANSHIATAL ENUCLEATION

Diseases of the Esophagus ◽

10.1093/dote/doz092.172 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Bernardi Daniele ◽

Porta Matteo ◽

Asti Emanuele ◽

Siboni Stefano ◽

Lazzari Veronica ◽

...

Keyword(s):

High Resolution ◽

Esophageal Motility ◽

Epigastric Pain ◽

Benign Tumors ◽

Upper Gastrointestinal Endoscopy ◽

Suture Repair ◽

Toupet Fundoplication ◽

Hrql Score ◽

High Resolution Manometry ◽

Luminal Narrowing

Abstract Aim To describe an unusual case of benign esophageal submucosal tumor. Background Esophageal lipomas account for less than 1% of benign tumors of the esophagus, which represent less than 1% of all esophageal neoplasms. The presence of a concomitant esophageal motility disorder may be underestimated in patients with benign esophageal submucosal tumors. Case report A 77-year-old man was referred for a 12-year history of daily heartburn, occasional dysphagia progressively worsening during the last few months, and more recent onset of epigastric pain, regurgitation, and weight loss. Empirical therapy with proton-pump inhibitors was ineffective. The GERD-HRQL score was 22. Physical examination was unremarkable. Upper gastrointestinal endoscopy showed a soft submucosal mass in the posterior wall of the lower third of the esophagus, 3 cm above the esophago-gastric junction. The endoscopic finding was confirmed by a chest CT scan that documented a submucosal esophageal lesion with luminal narrowing. High resolution manometry did not reveal EGJ obstruction but showed a pan-esophageal pressurization in 100% of the swallows. The patient underwent laparoscopic transhiatal enucleation of a 11x4 cm mass, suture repair of the esophageal muscle layer, posterior cruroplasty, and 270° Toupet fundoplication. The postoperative course was uneventful. A gastrographin swallow study on day 1 showed the normal esophagogastric transit and the absence of leaks. The patient was discharged on postoperative day 2. Pathology confirmed the clinical suspicion of esophageal lipoma. At 3-month follow-up visit the GERD-HRQL score was 7 and the patient was very pleased with the results of the operation. Conclusion Esophageal lipoma is very rare. Laparoscopic transhiatal enucleation was feasible and safe in our experience. The choice of a Toupet fundoplication was justified by the finding of ineffective esophageal motility on high-resolution manometry.

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P150 ULCERATING CMV ESOPHAGITIS – A UNIQUE COMPLICATION OF ACHALASIA

Diseases of the Esophagus ◽

10.1093/dote/doz092.150 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

F Corvinus ◽

H Neumann ◽

B Babic ◽

I Kovalets ◽

P Grimminger

Keyword(s):

High Resolution ◽

Complete Remission ◽

Symptom Relief ◽

Barium Swallow ◽

Residual Pressure ◽

Type Ii ◽

Laparoscopic Myotomy ◽

Inflammatory Infiltration ◽

High Resolution Manometry ◽

Endoscopic Placement

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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