Abstract Background Cricopharyngeal bar is a recognised cause of upper oesophageal sphincter dysfunction and can lead to significant oropharyngeal dysphagia. This condition predominantly affects elderly patients who often have multiple co-morbidities. Cricopharyngeal Per Oral Endoscopic Myotomy (C-POEM) has been described in limited case series, showing symptom relief and reduced procedural morbidity. In this study, we aim to evaluate the safety and feasibility of C-POEM in this high-risk population. Methods C-POEM cases performed at Royal Perth Hospital from November 2023 to December 2024 were included. Sydney Swallowing Questionnaire (SSQ) score and EndoFLIP planimetry distensibility index (DI) measurements were reviewed from a prospectively collected database. SSQ was calculated pre C-POEM as well as 6 weeks and 3 months post C-POEM. DI measurements were taken pre C-POEM and 3 months post C-POEM. Electronic records were reviewed to calculate patients’ Charlson co-morbidity index (CCI). Adverse events were recorded from clinic follow-up visits. Results Nine patients with a median age of 79 years underwent C-POEM. SSQ and DI results available in 8 and 6 patients respectively. 4 patients had a diagnosis of inclusion body myositis. The mean CCI score was 5.9. Technical success was achieved in all cases. The median reduction in SSQ was from 1011 to 271 and the median improvement in DI was 1.6 to 4.5. Median follow up was 34.9 weeks. There was one adverse event in which a patient aspirated from post-procedure swallow study due to being given barium instead of non-ionic contrast. One patient died from community acquired pneumonia. Conclusion This study demonstrates the feasibility and safety of performing C-POEM in a co-morbid group of elderly patients. Technical success was achieved in all cases and clinical improvement was seen in all cases at 6 weeks follow up supported by reduction in SSQ. If expertise is available, C-POEM should be considered for elderly patients with symptomatic cricopharyngeal bar.

Abstract Background Volatile organic compounds (VOC) in stool samples may reflect functional activity of gut microbiome. Previous studies showed that gut flora may influence transient relaxations of lower esophageal sphincter through short-chain fatty acids production and thus—participate in pathogenesis of gastroesophageal reflux disease (GERD). However, the role of VOC in pathogenesis of GERD is poorly studied yet. The aim of this study was to perform correlation analysis between concentrations of VOC in stool samples and GERD-Q score. Methods We enrolled willing to participate patients referred to perform multichannel 24-h pH-impedance recording (Ohmega, Laborie). According to the Lyon 2.0 criteria patients were allocated to the GERD or the control group. GERD-Q questionnaire was filled in by the participants on the same day as stool samples were collected. Thermo TSQ 8000 triple quadrupole mass-spectrometer (GC/MS) was used for the measurement of VOCs in stool samples were analyzed with. Correlation analysis (Spearman rank R) was performed between values of 80 VOCs in stool samples and the results of GERD-Q questionnaire. Results Data of 76 patients were eligible: 42 with GERD and 34—of the control group. Participants in the GERD group were older (54.7 ± 12.2 y.o. vs 46 ± 14.9 y.o., P < 0.05) and their BMI was greater (30.9 ± 5.2 vs 27.2 ± 6.5 kg/m2, P < 0.05). GERD-Q score was logically greater in GERD group (11.0 ± 2.5 vs 5.2 ± 1.2, P < 0.01). Correlation analysis revealed significant correlations between GERD-Q score and concentrations of 2-Methylbutyric acid (Spearman R = -0.31), Caproic acid (0.34) and Enantiic acid (0.396) in stool samples. Conclusion GERD-Q score positively correlates with concentrations of Caproic acid (0.34) and Enantiic acid (0.396) in stool samples and negatively—with 2-Methylbutyric acid. The data of this pilot study may serve as a basis for further research on the role of functional activity of gut microbiome in pathogenesis of GERD. This study was performed with the support of Ministry of Science and Higher Education of Russia (research project FGMF-2025-003).

Abstract Background Achalasia is a primary motility disorder, which presented by dysphagia. The most effective treatment of the disease is surgical (peroral myotomy or laparoscopic myotomy). However, there are few studies which assess the changes in esophageal motility after surgery. The aim of our study was evaluating the changes in esophageal manometry in patients with achalasia after peroral endoscopic myotomy (POEM). Methods 43 patients with achalasia were consequently observed before and 1 year after POEM. Females predominated (28 subjects). All patients examined endoscopically, then high resolution manometry (HRM) was performed by Solar™ GI (MMS/Laborie, Netherland). Achalasia was defined as described in Chicago Classification 4.0. Eight patients had I type of achalasia, 24—II type and 11—III type. All patients were devided into two groups. Group A: in 35 patients the median Eckardt score decreased from 7 to 2. Group B: 8 patients were dissatisfied with the surgery. Results According to HRM the mean resting pressure (RP) of LES (lower esophageal sphincter) in group A reduced from 39.1 ± 2.7 mmHg to 18.9 ± 1.4 mmHg. Also we revealed the decrease in integrated residual pressure (IRP) from 22.8 ± 0.7 to 9.8 ± 0.6 mmHg and DCI (distal contractile interval): from 1865.5 ± 286.9 to 128.2 ± 53.8 mmHg*s*cm. In a group B the mean RP of LES reduced from 48.8 ± 2.4 to 33.6 ± 2.4 mmHg. The IRP decreased from 22.8 ± 0.7 mmHg to 15.01 ± 0.6 mmHg and DCI: from 2999.6 ± 417.6 mmHg*s*cm to 1038.1 ± 107.7 mmHg*s*cm. Conclusion The reduction of resting pressure, integrated resting pressure and distal contractile interval can be accepted as criteria of POEM effectiveness. Besides, in patients with III type of achalasia we must assess the absence of spastic contraction as additional criteria of POEM satisfaction.

Abstract Background Achalasia is rare in children. Recently, injection of botulinum toxin into the lower esophageal sphincter has been studied as an alternative to esophageal pneumatic dilatation or surgical myotomy as treatment for achalasia. The goal of this study was to assess the efficacy of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. Methods 25 patients with esophageal achalasia underwent laparoscopic Heller myotomy and Dor fundoplication for the last 10 years. There were 9 boys and 16 girls whose median age was 9.9 years. Clinical symptoms including dysphagia, chest pain, and regurgitation are not specific to achalasia, which may result in a 2-year to 3-year delay in diagnosis from the beginning of symptoms. Chest x-ray can demonstrate absence of the gastric air bubble. Barium esophagram—‘bird beak’ deformity in all patients. The esophagus was dilated. Endoscopy in all patients excluded of a peptic or neoplastic stricture. Results All operations were completed laparoscopically. The mean operating time was 56 minutes. All patients had an uneventful recovery, with a mean hospital stay of 6.1 days. Barium passage was markedly improved in all patients. 4 children (16%) had recurrence of achalasia symptoms wich underwent cardio dilatation by mechanical cardio dilatator with a good result in 3 children (12%). 1 patient underwent to dilatation 3 times without improvement of clinical symptoms. The patient was re operated. During the operation the stomach has deformation in site of primary operation which caused gastrostazis and dysphagia symptoms, which was corrected. Conclusion Laparoscopic Heller myotomy and Dor fundoplication were effective and safe for children and should be offered as a first-line treatment with esophageal achalasia. The short gastric vessels have to be divided to freeing the fundus, before Dor fundoplication. Don’t use dilatation or BoTx in first-line treatment. Second-line treatment—dilatation (in recurrent cases).

Abstract Background Esophageal achalasia is a motility disorder characterized by impaired relaxation of the lower esophageal sphincter and loss of esophageal peristalsis. While the peak age of diagnosis is reported to be in the 40s to 50s, it can also occur during childhood, though diagnosis in pediatric cases is often challenging. This study aimed to evaluate the efficacy and safety of peroral endoscopic myotomy (POEM) for esophageal achalasia in patients aged 20 years and younger. Methods A total of 281 patients who underwent POEM at our institution between April 2015 and July 2024 were included in this study. The patients were divided into two groups: those under 20 years old and those 20 years and older. Their clinical backgrounds and treatment outcomes were compared and analyzed. Results The study included 8 patients under 20 years old (Y group) and 271 patients aged 20 and older (A group). The median age was 16.5 years (Y) and 58 years (A), with a median disease duration of 7.5 and 54 months, respectively (P < 0.05). Prior treatments included balloon dilation (Y: 4, A: 52), POEM (A: 1), and Heller-Dor (A: 7). The Eckardt score improved from 6.6 ± 2.3 to 0.6 ± 0.7 (Y) and 5.1 ± 2.1 to 0.5 ± 0.8 (A). One A-group patient required ICU admission due to anesthesia-related aspiration, with no other major complications. Conclusion Pediatric and adolescent patients with esophageal achalasia are reported to have a shorter disease duration than adults, a trend also observed in this study. However, despite the shorter duration, childhood and adolescence are critical periods for physical development, making early diagnosis and treatment essential. Feeding difficulties in these patients can negatively impact both physical and mental health, potentially hindering growth and learning opportunities. Therefore, prompt diagnosis and treatment are crucial to prevent long-term adverse effects on development and overall well-being. POEM for esophageal achalasia was safe and effective even in pediatric and adolescent cases.

Background & Aims: Hysteresis is a change in strain for a given repeated stress; it is a material property of the viscoelastic tissues. We aimed to determine hysteresis of the esophagogastric junction (EGJ) in patients with esophageal achalasia and differences in EGJ hysteresis in different achalasia phenotypes. Methods: In a cross-sectional study design, we measured the change in EGJ distensibility index (DI) with repeated distensions (a marker of hysteresis), and the effects of atropine on the DI using functional lumen imaging probe in 40 patients with esophageal achalasia (types 1, 2 and 3). Results: The DI increased significantly with second distension (hysteresis) as compared to first distension, but not with subsequent ones. Atropine, which ablates active smooth muscle contraction, had no effect on the DI value. Type 1 esophageal achalasia patients and those with severe dilatation (stage III and IV disease) had a higher index DI and lower hysteresis, as compared to esophageal achalasia subtypes 2 and 3. Conclusion: A low DI following atropine suggests that the passive elements (viscoelastic properties) of EGJ are an important cause of low DI in esophageal achalasia. Hysteresis of the EGJ, a material property of the viscoelastic tissue, is different in different achalasia subtypes.

Abstract Introduction Achalasia is defined as a functional obstruction of the esophagus due to impaired relaxation of the lower esophageal sphincter (LES) with either absent or spastic peristaltic activity of the esophagus. Peroral Endoscopic Myotomy (POEM) traditionally involves an esophageal full-thickness myotomy. A significant side effect is gastroesophageal reflux. This study investigates if myotomy of the lower esophageal circular muscle is associated with reduced risk of gastroesophageal reflux while still maintaining similar control of mechanical symptoms compared to traditional full-thickness myotomy? Method 55 patients (29 males, median age 44 years) with achalasia were randomized to either full-thickness (n=28) or selective myotomy (n=27). The groups were comparable in characteristics and disease-specific variables. Swallowing-related symptoms, reflux symptoms (GSRS) and quality of life (SF-36) were recorded before and at defined times postoperatively. Result Preoperatively median Eckardt score (7 range; 3 – 11 in both groups) or the reflux item within the GSRS (2 and 1.5 (1 – 5)) in the full thickness and selective myotomy groups, respectively, did not differ. 12 months postoperatively, a median Eckardt score of 2 was reported in both groups (range; 0 – 3 vs 0 – 5) Reflux item in GSRS (median 1.5; range 1 – 4) as well as the mental and physical dimensions in the SF-36 did not differ between groups. Discussion In this study, reflux symptoms and Eckhardt one year after full-thickness and selective endoscopic myotomy did not differ in patients with achalasia. These results suggest that selective myotomy might be preferable in POEM However, more detailed analysis and longer follow-up are required to allow more firm conclusions.

Rarer than rare: managing an epiphrenic diverticulum in achalasia Video 1 Type II achalasia and a large epiphrenic diverticulum were diagnosed on barium esophagogram, esophagogastroduodenoscopy, high resolution manometry, and computed tomography before the patient underwent laparoscopic diverticulectomy, Heller myotomy, and Dor fundoplication. Fig. 1 Initial barium esophagogram showing a dilated esophagus with a prominent diverticulum above the lower esophageal sphincter.

The relationship between manometric changes and esophageal dilation on chest high-resolution computed tomography is well established in systemic sclerosis, but its association with extra-esophageal manifestations is inconsistent. This study aims to characterize manometric findings in systemic sclerosis patients and to determine potential associations with esophageal body dysmotility. Retrospective single-center study including adult systemic sclerosis patients who underwent conventional or high-resolution esophageal manometry. Demographic and clinical data were collected. Associations between esophageal motility and disease duration, immunologic profile, cutaneous and pulmonary involvement, as well as endoscopic or tomographic esophageal alterations were evaluated. A total of 76 patients were included. Conventional manometry was performed in 60 (78.9%), with aperistalsis observed in 23 (38.3%) and a normotonic lower esophageal sphincter in 45 (75.0%). Sixteen patients (21.1%) underwent high-resolution esophageal manometry, showing normal motility in 9 (56.3%), normotonic lower esophageal sphincter in 9 (56.3%), and hypotonic lower esophageal sphincter in 7 (43.8%). Overall, 46 patients (60.5%) had esophageal body dysmotility and 54 (71.1%) had normotonic lower esophageal sphincter. Most patients (84.2%) had limited cutaneous disease. Median disease duration was 5 years (interquartile range = 11) with mean age 54.1 ± 12.4 years. Seventy-one patients (93.4%) were females. Potential associations with manometric esophageal involvement were compared between patients with normal motility and dysmotility. Esophageal dilation on chest high-resolution computed tomography was more frequent among those with dysmotility (p = 0.005). No significant differences were found regarding disease duration, immunologic profile, modified Rodnan skin score, esophagitis, Barrett's esophagus, interstitial lung disease, forced vital capacity, or single-breath carbon monoxide diffusing capacity. Esophageal involvement was frequent in our sample, although the lower esophageal sphincter was more commonly spared. An association between esophageal dysmotility and its dilation on chest high-resolution computed tomography was found, highlighting the utility of chest high-resolution computed tomography for identification of upper gastrointestinal involvement in systemic sclerosis. No association was found between manometric changes and extra-esophageal manifestations.

Recent advances in various observation methods revealed several unique characteristics of oesophageal peristalsis and its disorders. However, a framework for understanding the oesophageal motility pattern is lacking. Here, we propose a simple mathematical model of the human oesophageal motility function. The model comprises central nervous system signals, enteric nervous system neurons (interneurons and motoneurons) and oesophageal smooth muscles. The neural function implements excitable dynamics at the oesophageal body and toggle-switch dynamics at the lower oesophageal sphincter. The local signal transmission in enteric nervous system and ‘the law of the intestine’ were also incorporated. The model behaviours can be understood using mathematical analysis, and we could reproduce the physiological dynamics of the normal oesophagus—deglutitive inhibition, unidirectional pulse transmission, restoration of lower oesophageal sphincter constriction and dilatation of the anal side of the pulse. In addition, we could reproduce various pathological motility patterns described in the Chicago classification by the combinations of parameter changes, which may provide insights into the possible pathogenesis of these disorders.

Peroral direct diverticulotomy: a salvage peroral endoscopic myotomy technique for patients with “blown-out myotomy”

Role of ligamentum teres cardiopexy during laparoscopic sleeve gastrectomy in patients with obesity with gastroesophageal reflux disease: a short-term retrospective study.

Aerophagia occurring during continuous positive airway pressure (CPAP) (C-aerophagia) in patients with obstructive sleep apnea can impede treatment. This study aimed to evaluate the use of bilevel positive airway pressure (BiPAP) for managing C-aerophagia. Fifty-one patients newly diagnosed with C-aerophagia who switched from CPAP to auto-BiPAP were monitored. Assessment criteria included flatulence, eructation, abdominal bloating, quantitative evaluation, and onset time. BiPAP effectiveness was categorized as excellent-E (no criteria met), slight-E (partially met), or poor-E (criteria met). C-aerophagia discomfort, including residual cases on BiPAP, was rated via a visual analog scale (VAS; 0 = none, 10 = extreme). Satisfaction with BiPAP was evaluated as positive or negative. BiPAP effectiveness was excellent in 80.4%, slight in 4.0%, and poor in 15.7% of the patients. The VAS scores decreased significantly with BiPAP compared with those with CPAP (p < 0.001). In the poor-E group, five patients reported positive satisfaction with BiPAP and showed reduced VAS scores. A reduction in 90th percentile expiratory positive airway pressure (EPAP) compared with the 90th-95th percentile pressure of CPAP was associated with resolved C-aerophagia, indicating that reducing expiratory pressure while maintaining airway patency is essential. However, eight patients with EPAP ≤ 6.5 cmH2O experienced C-aerophagia, probably due to upper esophageal sphincter relaxation, indicating that alternative treatments are needed. BiPAP completely or partially resolved C-aerophagia symptoms in 84.3% of the patients. Among patients with residual symptoms, 62.5% (5/8) reported reduced discomfort and expressed satisfaction. Its effectiveness is likely due to lower expiratory pressure; however, in some cases, it remains challenging.

Background/AimsProximal esophageal dysmotility and high psychological burden are common in individuals with esophageal or laryngopharyngeal reflux symptoms. However, the clinical significance of abnormal proximal motility remains unclear. Given that proximal esophagus consists of skeletal muscle, proximal esophageal motility may be influenced by psychological burden. This study aims to explore the relationship between psychological burden and proximal esophageal motility.MethodsPatients with esophageal or laryngopharyngeal reflux symptoms were retrospectively included. Esophageal hypervigilance and anxiety scale (EHAS) was used to evaluate the psychological burden in patients. Demographics, endoscopic findings, proximal and distal esophageal manometric parameters, and reflux burden were compared between patients with and without esophageal hypervigilance and anxiety. Multivariate logistic regression analysis was conducted to determine the relationship between psychological burden and proximal esophageal motility.ResultsA total of 341 subjects were enrolled. A greater proportion of patients with high EHAS had elevated upper esophageal sphincter (UES) basal pressure than those with normal EHAS (21.5% vs 11.8%, P = 0.024), while no significant difference was found in other proximal manometric parameters between the 2 groups. On multivariate analysis, high EHAS was independently associated with elevated UES basal pressure (OR, 2.19, P = 0.034).ConclusionsElevated UES basal pressure is more frequently seen in symptomatic patients with high esophageal hypervigilance and anxiety. When encountering patients with unexplained high UES basal pressure, psychological burden may play a potential role in these cases.

Background/AimsThe Lyon Consensus 2.0 (Lyon 2.0) revised gastroesophageal reflux disease (GERD) definitions, incorporating Los Angeles (LA) grade B as diagnostic and mean nocturnal basal impedance (MNBI) as supplementary evidence. Asian populations show differing impedance-pH thresholds, with lower acid exposure time (AET) and higher MNBI values. The clinical validity of MNBI in Asian GERD patients remains uncertain. This study evaluated Lyon 2.0’s applicability to Korean patients.MethodsFrom January 2021 to August 2023, GERD-suspected patients underwent endoscopy, manometry, and pH testing. MNBI was measured 5 cm above the lower esophageal sphincter. Patients with major motor disorders, organic diseases, or prior foregut surgery were excluded. GERD was defined by AET ≥ 4% or LA grades B-D; non-GERD by AET < 4%, LA grade A or normal Z line with < 40 reflux episodes/day. The optimal MNBI threshold was determined via receiver operating characteristic curve analysis.ResultsAmong 427 patients (mean age 57.7 ± 13.8 years, 37.2% male), 59 (13.8%) had GERD (10 endoscopically confirmed, 54 by AET ≥ 4%). Non-GERD accounted for 63.5% (n = 271), with 22.7% (n = 97) in the borderline group. MNBI correlated negatively with AET (r = –0.482, P < 0.01) and LA grade (r = –1.390, P = 0.005). The optimal MNBI threshold for GERD was 2167 Ω (sensitivity 0.86, specificity 0.75). Three LA grade A cases were reclassified as GERD-positive using this threshold.ConclusionMNBI significantly correlated with AET and LA grades, highlighting its diagnostic value in Korean GERD patients. However, regional variations suggest higher MNBI thresholds than Lyon 2.0 recommendations, warranting further studies to refine criteria for Asian populations.

Background: Esophageal achalasia is a rare motility disorder characterized by impaired lower esophageal sphincter (LES) relaxation and food stasis. Surgical interventions, including Heller myotomy with fundoplication or peroral endoscopic myotomy (POEM), effectively alleviate symptoms but induce significant anatomical and functional alterations. In various gastrointestinal surgeries, microbiota have been implicated in modulating clinical outcomes; however, their role in achalasia surgery remains unexplored. Methods: We performed a narrative literature search of various databases to identify studies exploring potential interactions between the gastroesophageal microbiota, achalasia pathophysiology, and surgical treatment, proposing clinical implications and future research avenues. Results: Chronic esophageal stasis in achalasia promotes local dysbiosis by facilitating aberrant bacterial colonization. Surgical restoration of esophageal motility and gastroesophageal transit induces substantial shifts in the microbial ecosystem. Analogous microbiota alterations following procedures such as fundoplication, gastrectomy, and bariatric surgery underscore the significant impact of mechanical modifications on microbial composition. Comprehensive microbiota profiling in patients with achalasia may enable the identification of dysbiotic phenotypes predisposed to complications, thereby providing personalized therapeutic interventions including probiotics, prebiotics, dietary modulation, or targeted antibiotic therapy. These insights hold promise for clinical benefits, including the mitigation of inflammation and infection, monitoring of surgical efficacy through microbial biomarkers, and optimization of postoperative nutritional strategies to reestablish microbial homeostasis, ultimately enhancing patient outcomes beyond conventional treatment paradigms. Conclusions: The gastroesophageal microbiota is a compelling mediator of surgical outcomes in achalasia. Future investigations integrating microbiological and inflammatory profiling are warranted to elucidate the functional role of the gastroesophageal microbiota and assess its potential as a biomarker and therapeutic target.

Achalasia is characterized by impaired lower esophageal sphincter (LES) relaxation, while Barrett's esophagus (BE) is typically associated with gastroesophageal reflux disease (GERD) which can occur with excess LES relaxation. This article will provide an overview of the diagnostic challenges, surveillance strategies, and management approaches in the coexistence of these two conditions. Data on outcomes and management of concurrent BE and achalasia are limited. Most commonly, GERD and subsequent BE may occur after therapies for achalasia directed at increasing LES relaxation, and recent papers have focused on GERD and BE outcomes after achalasia therapies. The coexistence of BE and achalasia represents a challenging clinical scenario that requires consideration of the pathophysiology, diagnostic approach, and management strategies for both conditions.

ABSTRACTObjectivesMyotonic dystrophy (MyD) adversely affects swallowing function from an early stage. However, the swallowing characteristics of patients with MyD, who rarely seek medical attention owing to a lack of subjective symptoms, remain unclear. We aimed to analyze multifaceted swallowing function tests, including high‐resolution manometry (HRM), in patients with asymptomatic MyD and evaluate the swallowing pathophysiology in these patients.MethodsWe included patients who underwent HRM and swallowing function tests, including videofluoroscopic swallow study (VFSS), at our hospital. We analyzed the results along with the clinical and demographic profiles of the patients, comparing them to those in a non‐MyD control group of patients with mild dysphagia.ResultsThe MyD group demonstrated significantly decreased swallowing motility on VFSS and reduced pharyngeal contraction force at all stages from the pharynx to the upper esophageal sphincter (UES) on HRM. In the non‐MyD control group, a weak negative correlation was observed between maximum pharyngeal contraction force and minimum UES pressure during swallowing. Conversely, in the MyD group, the minimum UES pressure remained consistently low, regardless of weak pharyngeal contraction force.ConclusionOur study confirmed that patients with MyD exhibited significant motor disorders of swallowing‐related muscles even when unaware of their dysphagia. While constant UES relaxation may help maintain swallowing, particularly for liquids, it hinders patients' ability to recognize their swallowing problems and can lead to sudden choking episodes. Early risk management and intervention are, thus, necessary for patients with MyD, even those unaware of their dysphagia.Level of EvidenceIV.

Rationale:Post-traumatic dysphagia is a severe complication of traumatic brain injury, particularly in cases involving medullary damage. The rare combination of cricopharyngeal achalasia and bilateral vocal cord paralysis presents substantial challenges, with profound swallowing dysfunction and increased aspiration risk. Current treatments primarily target cricopharyngeal dysfunction but lack effective solutions for concurrent vocal cord paralysis, highlighting the need for innovative therapeutic strategies.Patient concerns:A 15-year-old male presented with severe dysphagia, confirmed as upper esophageal sphincter (UES) dysfunction and bilateral vocal cord paralysis. The patient exhibited severe aspiration (grade V water swallowing test, penetration aspiration scale: score of 7) and elevated UES residual pressure (28.2 mm Hg, normal < 12.0 mm Hg).Diagnoses:Post-traumatic neurogenic dysphagia with cricopharyngeal achalasia and bilateral vocal cord paralysis secondary to medullary damage.Interventions:An individualized protocol combining vagus nerve magnetic stimulation (VNMS) and conventional rehabilitation was implemented. VNMS targeted the left vagus nerve using 5 Hz stimulation at 80% resting motor threshold, while rehabilitation included pulmonary exercises, balloon dilation therapy, and tongue base pressure training.Outcomes:Substantial improvements were observed. UES residual pressure decreased from 28.2 mm Hg to 2.7 mm Hg, penetration aspiration scale score improved from 7 to 2, and the functional oral intake scale increased from level 1 to level 6, enabling oral feeding and removal of the tracheostomy and gastric tube. No adverse events were reported.Lessons:This case highlights the potential of VNMS as a noninvasive and effective treatment for complex post-traumatic brain injury dysphagia involving cricopharyngeal achalasia and bilateral vocal cord paralysis. By addressing dual swallowing-related pathologies, VNMS offers a promising therapeutic approach in neurorehabilitation. Further research is warranted to validate these findings and explore broader clinical applications.

A case is reported where consuming the main meal at lunch and an earlier, smaller-sized dinner reduced averaged, refractory pre-bedtime reflux scores (over 5 days and, three months later, over 8 days) from a maximum of 3 (significant symptoms) to 0.23 ± 0.44, nocturnal reflux scores from 1 or 2 (mild to moderate symptoms) to 0.69 ± 0.85, and sore throat and cough scores from 1 or 2 to 0.85 ± 0.90. Anecdotal evidence suggested that mealtime and meal volume changes brought significant benefits for pre-bedtime and nocturnal gastro-oesophageal reflux (GER) but were less effective for laryngopharyngeal reflux (LPR) symptoms of early morning sore throat and cough. A review of the literature found that early meals before bedtime and reduced meal volumes were likely to reduce the risk of GER and developing GERD. When recumbent, it was reported that meals were digested more slowly and gastric emptying rates decreased. Meals were also digested faster in the morning than in the evening, even when awake, with circadian rhythm and air swallowing also influencing the metabolism and the absorption of food. These reports indicate a biochemical basis for the benefit of early meals before bedtime and reduced meal volumes to reduce the risk of GER. It was also reported that when recumbent, for meals close to bedtime or large meals, gravity could assist the backflow of stomach contents into the oesophagus, indicating a biophysical basis for GER. To understand the role of gravity in GER, values for hydrostatic pressure were calculated for pre-meal to meal volumes of 1000 ml and found to be from 2–23 mmHg, in the same order of magnitude as the reported tonically contracted lower oesophageal sphincter pressure of 15–30 mmHg. Hypothetical models are developed to show how gastric content (GC) and body orientation change the hydrostatic pressure on the lower oesophageal sphincter and influence the risk of GER in the fed state. In summary, it is likely there is both a biochemical and a biophysical basis for GER and LPR, with meals 5 hours before bedtime, or smaller meals before bedtime, over 5 consecutive days, together with a raised bed head and sleeping dominantly on the left-hand side, all likely to reduce refractory GER symptoms.