Severe Esophageal Dysmotility Research Articles

Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication

BackgroundSignificant controversy exists regarding the indications and outcomes after laparoscopic adjustable gastric banding (LAGB) conversions to laparoscopic sleeve gastrectomy (LSG).AimTo comprehensively determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes.MethodsSix hundred revision LSG (RLSG) and 1200 controls (primary LSG (PLSG)) were included. Patient demographics, complications, follow-up, and patient-completed questionnaires were collected.ResultsRLSG vs controls; females 87% vs 78.8%, age 45 ± 19.4 vs 40.6 ± 10.6 years, p = 0.561; baseline weight 119.7 ± 26.2 vs 120.6 ± 26.5 kg p = 0.961). Follow-up was 87% vs 89.3%. Weight loss in RLSG at 5 years, 22.9% vs 29.6% TBWL, p = 0.001, 10 years: 19.5% vs 27% TBWL, p = 0.001. RLSG had more complications (4.8 vs 2.0% RR 2.4, p = 0.001), re-admissions (4.3 vs 2.4% RR 1.8, p = 0.012), staple line leaks (2.5 vs 0.9%, p = 0.003). Eroded bands and baseline weight were independent predictors of complications after RLSG. Long-term re-operation rate was 7.3% for RLSG compared to 3.2% in controls. Severe oesophageal dysmotility predicted poor weight loss. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034).ConclusionRLSG provides long-term weight loss, although peri-operative complications are significantly elevated compared to PLSG. Longer-term re-operation rates are elevated compared to PLSG. Four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.Graphical

Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis.

During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy (GJ) may be deemed necessary for patients with severe oesophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative GJ tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients. We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a GJ tube with control patients on a 1:1 ratio. The preoperative, operative and postoperative outcomes of the patients were evaluated. After propensity score matching, 193 patients with GJ were compared to 193 patients without GJ. Patients with GJ had significantly higher rates of delayed chest closure (P = 0.007), and postoperative dialysis (P = 0.016), longer intensive care unit stays (P < 0.001), longer ventilator duration (P < 0.001), higher rates of pneumonia (P = 0.035) and higher rates of being treated for acute cellular rejection within 1 year of transplant (P = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (P = 0.09 and P = 0.3). GJ tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the GJ tube may be a useful option for enteral feeding.

Radionuclide Diagnosis of Esophageal Dysmotility and Gastroesophageal Reflux in Patients with Systemic Sclerosis

Objective: to evaluate the possibilities of dynamic scintigraphy for the diagnosis of esophageal dysmotility (ED) and gastroesophageal reflux (GER) in patients with systemic sclerosis (SS).Material and methods. The study group included 77 patients with established SS of different disease duration (from several months to 30 years) who underwent Technephyt 99mTc dynamic esophageal scintigraphy using two-stage protocol. During the first stage, the esophageal transport function was evaluated; during the second stage, the presence and severity of GER were assessed. Scans were analyzed using visual assessment, quantitative estimation of time/activity curves, and a proposed three-point scale for evaluating ED and GER severity. The control group consisted of 19 practically healthy individuals who underwent a routine examination to exclude digestive system and gastrointestinal tract diseases, the algorithm of which included dynamic scintigraphy.Results. ED was found in 74 of 77 patients (96%). According to three-point scale, severe ED (3 points) was registrated in 41 (55%) patients, moderate ED (2 points) in 15 (21%), and mild ED in 18 (24%). GER was diagnosed in 35 of 77 cases (45%): mild GER in 13 (37%), moderate GER (2 points) in 22 (63%), and none of the patients was found to have severe GER (3 points). A significant relationship between the presence of GER and the severity of ED was not obtained, but a direct correlation was established between ED and GER severity.Conclusion. Most SS patients demonstrated ED of varying severity associated with mild and moderate GER in nearly 45% of the cases. The study results confirm the practical significance of dynamic scintigraphy for assessing the esophageal transport function and GER in SS patients.

First Robotic Roux-en-Y Gastric Bypass for the Treatment of Refractory Gastroesophageal Reflux Disease in a Patient With Systemic Sclerosis.

Systemic sclerosis (SSc) is an immune-mediated disease that results in fibrosis of the skin and internal organs. Refractory gastroesophageal reflux disease (GERD) associated with severe esophageal dysmotility is common in SSc patients, and surgical treatment with usual anti-reflux procedures such as fundoplications is associated with dismal symptomatic relief and postoperative dysphagia. We report the first robotic short-limb Roux-en-Y gastric bypass (RYGB) with a short Roux limb for the treatment of GERD in a patient with SSc with intense esophageal dysmotility.The operativetime was two hours. The procedure and postoperative course were uneventful. The patient presented complete relief of gastroesophageal reflux symptoms and no postoperative dysphagia in a two-year follow-up.Therefore, short-limb RYGB is a safe and very effective alternative for the treatment of severe GERD in patients with SSc. The robotic surgical platform may have some advantages compared to conventional laparoscopy.

S2315 Epiglottic Calcification, a Rare a Cause of Dysphagia

Introduction: In consideration of dysphagia, most cases predominate in the oropharyngeal region with the remainder caused primarily by esophageal causes. Lesser known and studied is the development of dysphagia and globus sensation from epiglottic pathology, namely epiglottic calcification. With less than a dozen published cases in literature, very little data exists on identification, diagnosis, and treatment of this known cause of morbidity. Here we present a case of oropharyngeal dysphagia arising from a rare cause, epiglottic calcification. Case Description/Methods: An 81-year-old male with history of aortic stenosis and carotid artery stenosis presented with worsening dysphagia over the course of one month. The patient reported significant dysphagia initially to solids and subsequently to liquids causing a weight loss of over 50 pounds. Physical exam of oropharynx and neck was unremarkable. Bedside swallow evaluation suggested mildly decreased hyolaryngeal movement, but no other significant abnormalities were identified. A Barium swallow study revealed incomplete epiglottic excursion during the pharyngeal phase of swallowing. With gastroenterology consultation, patient underwent evaluation with contrast-enhanced esophagogram that showed severe esophageal dysmotility and reflux. CT of neck demonstrated calcification of epiglottis without epiglottal enlargement, which was ultimately found to be the source of his concern. Via ENT, the patient underwent flexible fiberoptic laryngoscopy, and via gastroenterology, patient underwent EGD with biopsy. Yet, no esophageal or gastric pathology other than epiglottic calcification were identified. As no definitive treatment modality was outlined despite evaluation, patient was changed to a modified diet with ongoing speech and swallow therapy with outpatient follow up (Figure). Discussion: Epiglottic calcification is a rare cause of dysphagia that is poorly understood in its etiology, clinical course and outcomes. With our case, we hope to add to literature a unique presentation and imaging. Furthermore, with our case it is demonstrated that despite consultant recommendations, no clear evaluation process or treatment modality currently exists, lending to further study of this pathology. Currently, diagnosis can be accomplished with radiologic evaluation along with exclusion of other causes; however, no definitive treatments are available for this condition. Although the condition itself is rare, it adds to the differential diagnosis as a cause of significant dysphagia.Figure 1.: Calcification of epiglottis (red arrow) visualized on CT scan.

P27 Challenging management of GI complications in Systemic Sclerosis

Introduction/BackgroundSystemic sclerosis is a chronic, progressive, multisystemic autoimmune disease in which there is excessive collagen deposition in the dermis and internal organs. It is commonly categorized into limited cutaneous or diffuse cutaneous systemic sclerosis. In more than 80% of patients there is GI involvement. Gut complications can impair oral intake, absorption and even faecal continence, and consequently can have severe adverse effect on quality of life. With disease progression, management of GI symptoms may become more of a challenge. We present a challenging case of SSs with esophageal involvement along with severe regurgitation who eventually responded to a specific prokinetic.Description/Method70 y/o female initially presented to gastroenterology clinic in 2013 due to dysphagia to solids and was found to have benign fibrotic oesophageal stricture for which she had therapeutic dilatation, (normal biopsy result). Subsequently, she had barium swallow which showed severe regurgitation. Manometry confirmed severely hypo-contractile oesophagus thus she was referred to rheumatology for suspected connective tissue disorder.On initial review, she did not describe typical inflammatory symptoms, scleroderma, sclerodactyly, Raynaud’s phenomenon, digital ulcers, calcinosis, telangiectasia or any other connective tissue features but was diagnosed with limited cutaneous systemic sclerosis due to ANA & anti-centromere antibody positivity, severe oesophageal dysmotility and diagnosis of mild pulmonary hypertension (on right heart catheter studies).Her main disabling SSs symptom was refractory belching, intermittent dysphagia and reflux disease resulting in poor oral intake and resultant malnutrition. She had 4-week trial of antibiotics to treat for presumptive small intestine bacterial overgrowth (SIBO) due to persistent belching but had no evident improvement. She had multiple endoscopies which only showed grade B oesophagitis due to which she remained on high dose PPI (Omeprazole 40mg BD) but showed no recurrent stricture. She was also given dual therapy with Ranitidine 150mg bd but derived no benefit.In Rheumatology clinic she was started on erythromycin 250 mg BD as a pro-kinetic and in liquid form for better tolerability (due to the dysphagia) with gradual but significant improvement of her upper GI symptoms. Switching liquid form to tablets/capsule form via GP resulted in worsening symptoms so was switched back to liquid form. GI symptoms worsened again in 2017 and impression was tachyphylaxis to erythromycin. She was started on trial of another pro-kinetic (metoclopramide) but symptoms continued worsening. In view of this she was started back on liquid erythromycin and her symptoms gradually improved again and has remained stable since.Discussion/ResultsSystemic sclerosis (SSc) is an incurable connective tissue disorder. It is estimated that approximately 90% of patients with SSc have some form of oesophageal involvement. For first three years, this patient’s main symptoms were her upper GI tract issues with reflux and oesophageal dysmotility causing delayed gastric emptying.Considering the severity of her GI symptoms, it was of great importance for her to maintain a regular follow up with gastroenterology team for a regular review of symptoms and repeat investigations as needed such as multiple repeat UGI endoscopy to ensure no recurrence of oesophageal stricture, monitoring of GORD, and hydrogen breath testing.We recommend for patients with severe oesophageal dysmotility to be started on prokinetics early to control GI symptoms and have minimal impact of these on quality of life. Liquid preparation has shown a significant improvement in symptoms in our patient as compared to tablet or capsule form which actually worsened the symptoms.Key learning points/ConclusionDysphagia can be a presenting symptom of systemic sclerosis in some cases. Upper gastro-intestinal symptoms can be severe with significant effect on quality of life.Management of these symptoms can be challenging and may require a combination of treatments.Pro-kinetics mainly erythromycin can have a major positive impact in controlling GI symptoms,Liquid form had better outcome in this case as compared to tablet or capsule form.Poor control of GI symptoms can result in significant malnutrition which is associated with more aggressive disease progression, so GI symptoms management plays a key role in disease control.

802 PERIOPERATIVE AND SHORT-TERM OUTCOMES FOR PRIMARY ANTIREFLUX SURGERY: FUNDOPLICATION VS. RNY RECONSTRUCTION

Abstract Laparoscopic fundoplication is the gold standard for treatment of gastroesophageal reflux disease (GERD); however, RNY reconstruction may be an alternative option in patients with complex pathophysiology and other risk factors. This study aimed to compare perioperative and short-term outcomes between primary fundoplication and RNY reconstruction. Methods After IRB approval, a prospectively maintained esophageal surgery database was retrospectively reviewed to identify patients who underwent primary fundoplication or RNY reconstruction from September 2016 to July 2020. We retrieved perioperative outcomes (operative time, length of hospital stay, intraoperative and postoperative complications) along with GERD-Health-Related Quality of Life (HRQL) scores at annual follow-up. Results During the study period, 226 patients underwent surgery (fundoplication: 210; RNY: 16). The most common indication for RNY was severe esophageal dysmotility or morbid obesity. There was only one conversion to open surgery due to adhesions (fundoplication group). The operative time, length of hospital stay, and ICU stay were significantly lower in the fundoplication group. Rates of intraoperative (fundoplication: 3% vs RNY: 0) and postoperative complications (Clavien-Dindo ≥II) (fundoplication: 3% vs RNY: 6%) were not significantly different between groups. Both groups had a significant and similar improvement of GERD-HRQL scores 1 year after surgery (Table 1). Conclusion Primary antireflux surgery is associated with low perioperative morbidity and excellent short-term outcomes. RNY reconstruction and fundoplication have similar outcomes. More liberal use of RNY reconstruction as the primary antireflux surgery in patients at high risk of failure with fundoplication should be explored.

Lung Transplantation in Systemic Sclerosis: a Practice Survey of United States Lung Transplant Centers.

We conducted a web-based survey of adult lung transplant programs in the United States regarding their practices in patients with SSc. Sixty percent (37/62) of the eligible centers responded to the survey, majority of the respondents were medical directors (81%). Most centers would consider transplanting patients with mild or moderate esophageal disease (92% or 75%, respectively) or gastroparesis (59%). A minority would consider patients with severe esophageal dysmotility (37%), digital ulcers (21%), or low body mass index (19%). Most centers conducted extensive pretransplant gastrointestinal evaluation and use a conservative feeding approach with prolonged nothing by mouth (83%) and postpyloric feeding (89%). Antireflux surgery is commonly considered (40%) with partial fundoplication being the procedure of choice (67%). Most respondents expected similar outcomes of acute or chronic rejection (81% and 51%, respectively), respiratory infections (76%), and 1-year survival (70%). Most US lung transplant centers do not universally exclude SSc from lung transplant listing, but most support extensive pretransplant gastrointestinal testing and a conservative approach to feeding in the early posttransplant period.

Oesophageal dysmotility in a dog following surgical correction of an oesophageal perforation

AbstractA 9‐year‐old, male neutered Jack Russell terrier, weighing 6.7 kg, required general anaesthesia for retrieval of an oesophageal foreign body (OFB) of 7 days' duration. Removal of the osseous foreign body with oesophagoscopy was successful but revealed severe oesophageal necrosis with two full thickness tears of the caudal thoracic oesophagus prompting surgical intervention. Bilateral thoracotomy was performed, and the oesophageal lesions were successfully apposed. A gastrostomy tube was placed to provide nutrition until oral feeding resumed. Fourteen days post‐operatively the dog began to regurgitate with increasing frequency. Oesophagoscopy was repeated and revealed healing of the oesophageal lesions. Thoracic radiography was also normal. A fluoroscopic barium swallow study was performed 24 days post‐operatively which revealed severe oesophageal dysmotility of the caudal thoracic oesophagus. To the authors’ knowledge, this is the first report of severe oesophageal dysmotility as a delayed, post‐operative complication of oesophageal surgery following complete perforation by an osseous OFB.

Reflux Aspiration Associated with Oesophageal Dysmotility but Not Delayed Liquid Gastric Emptying

Introduction: Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility. Methods: Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed. Results: Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03). Conclusion: Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.

Predictors of reflux aspiration and laryngo-pharyngeal reflux.

Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms. Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed. Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01). Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

1764 It’s Not Always Reflux: The Role of High-Resolution Manometry in Management of Patients With Sleeve Gastrectomy

INTRODUCTION: We present cases of esophageal motility disorders associated with sleeve gastrectomy and identify the role of high-resolution manometry (HRM) in perioperative diagnosis and management. CASE DESCRIPTION/METHODS: Case 1: A 44-year old female with history of morbid obesity and gastric reflux presented with persistent symptoms of regurgitation, vomiting, and refractory reflux after undergoing a sleeve gastrectomy two years prior. Upper endoscopy showed slight resistance to endoscope passage at the lower esophageal sphincter and HRM evaluation was consistent with Type II achalasia, a finding confirmed by barium esophagram. The patient underwent a Heller myotomy with conversion into gastric bypass. On follow-up, patient noted no further recurrence of her presenting symptoms. Case 2: 52-year old female with multiple comorbidities presented with refractory dysphagia. She had undergone sleeve gastrectomy 5 years prior and subsequently developed worsening postprandial chest pain and solid food dysphagia. Outside work up of her dysphagia including multiple endoscopies and an esophagram were negative. On present evaluation, a 13 mm Barium pill traversed the esophagus without delay, and HRM showed a hypercontractile esophagus with high normal integrated relaxation pressure. The patient was started on antispasmodic therapy with symptom improvement. DISCUSSION: Laparoscopic sleeve gastrectomy is a bariatric surgical procedure for rapid weight loss in those classified as morbidly obese. The procedure leaves patients with a narrow tubular stomach roughly the diameter of the esophagus. Post operatively, patients have been noted to experience dysphagia, odynophagia, and most commonly (19.7% of cases) reflux. In our cases, patients experienced severe esophageal dysmotility which may have been caused by post-operative alterations of gastric anatomy and pressures. The mechanism behind post-operative motility disorders is unclear, and some studies have suggested that the procedure may unmask previously latent or subclinical disorders rather than induce them. We believe that HRM should be used as part of high value care in evaluating gastric sleeve patients with esophageal symptoms, especially before surgical revisions. Braghetto, I., et al. OBES SURG (2010) 20: 357. https://doi-org.elibrary.amc.edu/10.1007/s11695-009-0040-3.

1807 Esophageal Melanocytosis: An Uncommon Finding

INTRODUCTION: Esophageal melanocytosis is a benign, rare melanocytic proliferation in the basal layer of the squamous epithelium. The etiology of the melanocytosis is not clear; however, it has been suggested that aberrant migration during embryogenesis and chronic irritation such as GERD could lead to its occurrence. While largely asymptomatic, these proliferations raise concern for mucosal melanoma. CASE DESCRIPTION/METHODS: A 69-year-old Trinidadian female with past medical history of gastroesophageal reflux disease (GERD) presented with a two week history of dysphagia. Physical examination did not reveal any cutaneous or mucocutaneous lesions. Neurological exam also was normal. A computerized tomography (CT) scan showed circumferential wall thickening and moderate patulous proximal esophagus. A barium esophagram revealed severe esophageal dysmotility and GERD. Given dysphagia and CT findings, an esophagogastroduodenoscopy (EGD) was performed revealing hyperpigmented mucosa in the lower third of the esophagus (Figure 1A). Biopsies revealed melanin within the basal squamous epithelium with evenly spaced melanocytes and pigmented dendritic processes (Figure 1B). Immunohistochemistry for Melan-A and SOX10, a nuclear marker of melanocytes, highlighted these melanocytes without nesting or pagetoid scatter (Figure 1C). The patient was scheduled for a follow-up EGD for monitoring in 12 months. DISCUSSION: Endocscopically, anal and colonic lesions have been discovered along with esophageal lesions. Esophageal lesions largely present in the middle and lower third of the esophagus. Initial visualization of these lesions should be managed with a biopsy to determine if melanoma is present. Should esophagael melanocytosis be discovered on biopsy, repeat EGD with biopsy is recommended as early melanoma-in-situ may closely mimic esophageal melanocytosis.

3099 Endoscopic Botulinum Toxin Injection for Tacrolimus-Induced Achalasia in a Renal Transplant Recipient

INTRODUCTION: Multiple medications have been associated with secondary achalasia. Here we present a patient who developed dysphagia 4 days after his renal transplant and was found to have achalasia thought to be due to his tacrolimus; he was successfully treated with botulinum injection. To our knowledge, this is the first case of tacrolimus-induced achalasia ever reported in a renal transplant patient; it is also the first case in a transplant patient to be treated endoscopically with botulinum injection. CASE DESCRIPTION/METHODS: A 58 year old man with a history of end stage renal disease secondary to focal segmental glomerulosclerosis presented with progressive renal failure and underwent deceased kidney transplant without complications. At clinic, follow-up on post-operative day #4, the patient reported difficulty in swallowing since post-operative day two. A modified barium swallow study (Figure 1) demonstrated severe esophageal dysmotility and lower esophageal sphincter dysfunction concerning for achalasia. Upper endoscopy (Figure 2) one week later revealed a dilated esophagus with mild edema but without focal lesions or ulcerations. Esophageal manometry (Figure 3) evidenced outflow obstruction of the esophagogastric junction and weak peristalsis in the esophageal body, confirming the diagnosis of achalasia. Surgical therapy and changing his calcineuron inhibitor for achalasia were considered too high risk in this patient so shortly after transplant. The patient ultimately underwent therapy with endoscopic botulinum toxin injection (100 units) of the lower esophageal sphincter. He had excellent results with immediate and complete resolution of dysphagia. DISCUSSION: The proposed mechanism for CNI induced changes in esophageal motility involves inhibition of nitric oxide synthase by CNIs. Nitric oxide (NO) is responsible for esophageal peristalsis as well as relaxation of the lower esophageal sphincter (LES). Although it is unclear why switching between different CNIs would lead to symptom resolution, individual variation in the reaction to the different chemical structures of tacrolimus and cyclosporine has been proposed. Botulinum toxin can be considered as a therapeutic option in those patients who are not candidates for a change in their immunosupression. To our knowledge, this is the first case of botulinum induced achalasia reported after a kidney transplant and also the first successfully treated with botulinum toxin injection.

Black lesions in the oesophagus

A 69-year-old Trinidadian woman with a past medical history of gastro-oesophageal reflux disease (GERD) presented with a 2-week history of dysphagia. Physical examination did not reveal any cutaneous or mucocutaneous...

Partial fundoplication may be an effective therapy for gastroesophageal reflux disease for patients with severe esophageal dysmotility

We appreciate Dr. Herbella’s thorough review on our article. Indeed, the updated classification on esophageal dysmotility based on high-resolution manometry brings a new perspective for the treatment of patients with gastroesophageal reflux disease (GERD). Due to the high prevalence of GERD, and its commonly related esophageal conditions, is it crucial to understand not only the benefits of surgical treatment for this disease, but also which surgical technique is most appropriate in this scenario. This is particularly important for patients with severe esophageal dysmotility, who often present with dysphagia after fundoplication, requiring additional postoperative dilations and continuous use of anti-reflux medication (1).

Partial fundoplication may be an effective therapy for gastroesophageal reflux disease for patients with severe esophageal dysmotility

Partial fundoplication may be an effective therapy for gastroesophageal reflux disease for patients with severe esophageal dysmotility

Surgical Management of Gastroesophageal Reflux Disease in Patients with Severe Esophageal Dysmotility

BackgroundGastroesophageal reflux disease (GERD) and esophageal dysmotility are often disqualifying criteria for fundoplication due to dysphagia complications. A tailored partial fundoplication may improve GERD in patients with severe esophageal motility disorders. We evaluate this approach on GERD improvement in non-achalasia esophageal dysmotility patients. MethodsA single-institution prospective database was reviewed (2007–2016), with inclusion criteria of GERD, previous diagnosis of non-achalasia esophageal motility disorder, and laparoscopic partial fundoplication. Diagnosis of previous achalasia diagnosis or diffused esophageal spasm was excluded. Motility studies, pre- and post-upper gastrointestinal imaging (UGI), esophageal symptom scores, antacid, and PPI use were collected pre-op, 6 months, 12 months, and long-term (LT). Statistical analysis was made using SPSS v.23.0.0, α = 0.05. ResultsFifty-two patients met the inclusion criteria. A total of 17.3% had esophageal body amotility, 79.6% had severe esophageal dysmotility. A total of 65.9% women (mean age 64 ± 15.7), mean peristalsis 45.3 ± 32.6%, and failed peristalsis 36.0 ± 32.2%. Mean LES residual pressure was 15.0±18.0 mmHg, and 40.7% had hypotensive LES. Mean follow-up time was 25 months [1–7 years], with significant improvement in symptoms and reduction in PPI and antacid use at all time-points compared to pre-op. A total of 74% had UGI studies at 12 months; all showed persistent dysmotility. Six patients had radiographic hiatal hernia recurrence, with only one being clinically symptomatic postoperatively. Three required dilation for persistent dysphagia. ConclusionsA tailored partial fundoplication may be effective in symptom relief for non-achalasia patients with esophageal motility disorders and GERD. Significant symptom improvement, low HHR, and PPI use clearly indicate this approach to be effective for this population.

PS01.062: REFLUX ASPIRATION SURGICAL OUTCOMES: DOES LAPAROSCOPIC FUNDOPLICATION SIGNIFICANTLY DECREASE QUANTITATIVE AND SYMPTOMATIC PULMONARY ASPIRATION?

Abstract Background Pulmonary aspiration of gastric refluxate is one of the indications for anti-reflux surgery. Effectiveness of surgery in preventing pulmonary aspiration post-operatively has not been previously tested. Methods Retrospective analysis of prospectively populated database of patients with confirmed aspiration of gastric refluxate on scintigraphy. Patients that have undergone anti-reflux surgery between 01/01/2014 and 31/12/2015 and had scintigraphy post-operatively were included. Objective data such as resolution of aspiration, degree of proximal aero-digestive contamination, surgical complications and oesophageal dysmotility as well as patient quality of life data was analysed. Results Inclusion criteria were satisfied by 39 patients (11 male and 28 female). Pulmonary aspiration was prevented in 24 out of 39 patients (61.5%) post operatively. Significant reduction of isotope contamination of upper oesophagus supine and upright (P = 0.002) and pharynx supine and upright (P = 0.027) was confirmed on scintigraphy post operatively. Severe oesophageal dysmotility was strongly associated with continued aspiration post-operatively OR 15.3 (95% CI 2.459–95.194; P = 0.02). Majority (24/31, 77%) of patients were satisfied or very satisfied with surgery, whilst 7/31 (23%) were dissatisfied. Pre-operative GIQLI scores were low (mean 90.5, SD 18.8), modest improvements at 6 months (mean 92.8, SD 23.9) and 12 months (mean 92.2, SD 27), were not significant (P = 0.07). Conclusion Surgery is partially effective in reversing pulmonary aspiration of gastric refluxate on short-term follow up. Severe oesophageal dysmotility is a predictor of inferior control of aspiration with surgery. Overall satisfaction with surgery in patients with pulmonary aspiration is inferior compared to other patients undergoing anti-reflux surgery. Disclosure All authors have declared no conflicts of interest.