82 A Case of Physiology Surveillance for Oesophageal Surgery

Abstract Case Study 22-year-old Caucasian female (BMI 18.7) with reflux symptoms and endoscopic hiatus hernia underwent oesophageal physiology study to consider antireflux surgery. However, she required another physiology study 23-months later for severe dysphagia and weight loss in consequence of developing achalasia (BMI 15.5). The physiology studies changed the surgical management which is discussed in this paper. Method Oesophageal physiology tests composed of high-resolution manometry (HRM) and 24-hour impedance-pH (MII-pH) studies. Discussion The primary physiology suggested non-relaxing lower oesophageal sphincter (LOS) based on unchanged pressures during swallows despite recording normotensive readings (≈8.5mmHg). In the oesophageal body motility, ineffective oesophagus was diagnosed (70% weak peristalsis, mean DCI 268mmHgscm, distal latency 4.6s) with normal mean wave amplitude (54.6mmHg) and multiple water swallows increased the peristaltic vigour by a factor of 2.91. The ineffective oesophagus would not contraindicate LINX procedure or partial fundoplication. However, the antireflux surgery was not considered because MII-pH study captured one acid reflux episode (AET 0%, DeMeester score 0.8), which is compatible with non-relaxing LOS. The longest impedance clearance time was normal from the weak peristalsis (9.8s). The second physiology revealed severe form of achalasia (subtype I) based on dry swallows, standard 5ml water swallows, multiple water swallows and solid bolus swallows. The impedance transit was consistent with achalasia from poor clearance (clearance rate 0.69cm/s, total transit time 33.9 minutes). Conclusions The pre-achalasia state manifested as ineffective oesophagus with reflux symptoms. However, the non-relaxing LOS feature and the peristaltic latency borderline to spasm should warrant oesophageal physiology surveillance.