Oesophageal pain: A tough nut to crack the role of high resolution manometry guided segmental oesophageal myotomy

Abstract

Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function. Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux. Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms. Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function. Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.