You recently reported a case of gastric dysmotility. Here is another case which I am currently re-evaluating.
The patient is a 44 year old school teacher with asthma and severe reflux symptoms who was referred to me last year for what was initially felt to be a large hiatal hernia. Attempts at esophageal manometry were unsuccessful because the patient had a hyperactive gag reflex. They were unable to intubate her. The patient refused 24 pH monitoring. Video esophagogram showed a paraesophageal hernia. Esophageal motility was poor with poor emptying of the distal esophagus and tertiary contractions.
She required urgent exploration for symptoms of nausea, vomiting and epigastric abdominal pain. A laparoscopic reduction of the paraesophageal hernia was performed. Because of the abnormal video esophagogram, a partial 180 Toupet posterior fundiplication was done. A percutaneous gastrostomy tube was also placed.
Postoperative video esophagogram showed reflux in the supine position only. The patient initially did well with an improvement in her reflux symptoms. Her asthma was only slightly improved.
Over the past year, the patient’s asthma has worsened again. She intermittently requires steroids. Her reflux symptoms are slightly worse. Her pulmonologist feels that her reflux disease is the major contributing factor. She has been Prevacid 30 mg QD and Propulsid 10 mg QID.
Repeat video esophagogram showed worsening reflux in both upright, prone and supine positions with valsalva. There was no evidence of a slipped fundiplication or paraesophageal hernia recurrence. Esophageal motility appeared improved. The patient finally agreed to undergo 24 ph monitoring. She was difficult to intubate but this was accomplished. The study was very abnormal with reflux in all positions. DeMeester score was 168.3. Repeat attempt as esophageal manometry was successful. This revealed a slightly low lower esophageal sphincter pressure at 16.8 mmHg (average normal 24 mmHG) with normal relaxation during a swallow. No hiatal hernia was noted. There was a normal pattern of contractions in the distal esophagus. The patient has a slightly low contraction amplitude in the upper esophagus. The upper esophageal sphincter was normal. A radionuclotide gastric emptying study is delayed with the T1/2 being 155 minutes (normal is <45 minutes).
Currently the patient is miserable with her reflux symptoms and asthma. I am contemplating doing a laparoscopic pyloroplasty possibly with a conversion of the Toupet to a complete Nissan.
Does anyone have any other thoughts?