Achalasia After Bariatric Surgery

Andrea Zelisko, MD, Hector Romero Talamas, MD, Ali Aminian, MD, Esam Batayyah, MD, Kevin El-Hayek, MD, Stacy Brethauer, MD, FACS, Philip Schauer, MD, FACS, Thomas Rice, MD, FACS, Matthew Kroh, MD, FACS

Department of Surgery at Cleveland Clinic

INTRODUCTION
Obesity is an exceedingly common chronic disease-a disease for which the incidence continues to rise and is linked to many comorbidities. Investigations between gastrointestinal motility and obesity are increasing and have shown a high prevalence of esophageal motility disorders in this population. There is incomplete and contradictory evidence on the impact of bariatric surgery on esophageal motility.
Achalasia is a rare esophageal motility disorder with a reported incidence of ~1.5/100,000. Very limited data exists on achalasia in the obese population and especially in those undergoing bariatric surgery. Furthermore, morbidly obese patients can have an atypical or even asymptomatic presentation of achalasia. Analysis from small reviews, reports an incidence of 0.5-1% in obese patients. Even less has been documented about the presence of achalasia after bariatric surgery. Current literature only documents two patients with achalasia and a history of bariatric surgery. With the intent to better delineate an association between bariatric surgery and achalasia, we sought out data from patients at our institution who developed achalasia and previously underwent a bariatric procedure.

METHODS AND PROCEDURES
Through a retrospective chart review, patients with a surgical intervention for achalasia during a ten year period were identified by an electronic medical records (EMR) search using CPT codes. Each patient’s EMR was reviewed for a history of bariatric surgery. Once the patients who met both the criteria were identified, a more dedicated review of their EMR occurred and patient information was constructed into a database.

RESULTS
After a review of 282 patients who had a Heller myotomy at the Cleveland Clinic from 2001 until 2012, five patients were identified that had prior bariatric surgery. Four of five patients had Roux-en-Y gastric bypass (RYGB) for their bariatric surgery (one patient had vertical banded gastroplasty that was converted to RYGB). Of the patients who had only the RYGB, their initial body mass index (BMI) was over 50kg/m2, and for three of them, over 60kg/m2. The average and mean time from bariatric surgery to diagnosis of achalasia was five years. All patients had formal diagnosis of achalasia, including esophograms, esophagogastroduodenoscopy, and manometry.

CONCLUSIONS
We detailed our history of patients who had surgical intervention for achalasia along with a history of bariatric surgery. Unfortunately, preoperative esophageal symptoms (prior to bariatric surgery) were not clearly documented in the EMR. The possibility exists that these patients may have had motility disorders prior to initial surgery, but they were not identified or asymptomatic. Although the incidence of achalasia in the bariatric population is unknown, it does coexist and should be addressed when evaluating patients. Furthermore, since obesity and achalasia are treated with different surgical techniques when they occur independently, early identification of concomitant disease would help tailor individual patient care.
As obesity continues to rise to epidemic proportions and surgery continues to be the only long-term effective therapy for morbid obesity, the presentation and identification of achalasia in obese patients, and more generally esophageal dysmotility, needs to be recognized as it can affect pre and postoperative management.

Session: Poster Presentation

Program Number: P432