89 From Ineffective Oesophagus to Achalasia: Tailoring the Surgical Plan

Abstract Introduction Achalasia features were identifiable in ineffective oesophageal motility (IOM) that altered patient’s surgical plan. Case Study 22-year-old Caucasian female (BMI 18.7) with reflux symptoms and endoscopic hiatus hernia underwent preoperative physiology for antireflux surgery. High-resolution manometry (HRM) raised suspicion of a non-relaxing lower oesophageal sphincter (LOS) based on similar tone and relaxation pressures despite normotensive (≈8.5mmHg). In the oesophageal body, 70% weak peristalsis terminated at the crura diaphragm level (mean DCI 268mmHgscm, distal latency 4.6s) with normal mean wave amplitude (54.6mmhg) and the multiple water swallowing (MWS) increased the peristaltic vigour by a factor of 2.91. IOM posed no contraindication for LINX procedure or partial fundoplication. The antireflux surgery was halted by the 24-hour multichannel impedance-pH (MII-pH) study only capturing one acid reflux episode (DeMeester score 0.8), which was also compatible to a non-relaxing LOS. The longest impedance clearance time during mealtimes was normal in IOM (9.8s). After 23-months, the patient had a second physiology study for severe dysphagia and weight loss (BMI 15.5) which showed development of severe achalasia (subtype I). This was consistent on all HRM swallow tests (dry, single-water, MWS and solid bolus) and impedance transit test revealed poor clearance (clearance rate 0.69cm/s, total transit time 33.9 minutes). patient went onto having a successful surgical myotomy. Conclusions Pre-achalasia manifest as IOM with reflux symptoms. However, evidence of non-relaxing LOS and borderline distal latency to oesophageal spasm warrants repeat physiology prior to surgical intervention.