John-Paul Bellistri, MD, Aida Taye, MD, Mujjahid Abbas, MD, Diego Camacho, MD. Montefiore Medical Center.
Background
Achalasia is the most common esophageal motility disorder, and myotomy remains the most effective treatment option available1. Morbid obesity itself is an independent risk factor for esophageal motility disorders2. Most morbidly obese patients with esophageal motility disorders are asymptomatic2. Numerous case reports describe the concurrent diagnosis and treatment of achalasia in patients undergoing bariatric surgery3-5. However, patients developing achalasia having already undergone a bariatric procedure is not commonly described in the literature.
Subject
A 51 year old woman with a history of morbid obesity presented to our clinic with complaints of solid and liquid food dysphagia. Her surgical history was significant for prior laparoscopic gastric band placement five years prior, followed by a revision with laparoscopic roux-en-y gastric bypass (LRYGB) three years prior, and subsequent 70 pound weight loss. Esophageal manometry was performed and exhibited aperistalsis of the esophagus with failure of relaxation of the lower esophageal sphincter. Barium swallow and endoscopic studies were also performed confirming a diagnosis of achalasia. The patient was then scheduled for laparoscopic Heller myotomy.
Procedure
The patient was placed in supine position. An optical trocar was utilized to obtain entrance into the abdomen. A four port configuration with Nathanson liver retractor was utilized for the procedure. A lysis of adhesions was performed to expose the gastric remnant and gastrojejunal anastomosis. The right and left crus were identified and the esophagus was then dissected free approximately 7cm into the thoracic cavity. Electrocautery was then utilized to begin the myotomyover the stomach from approximately 4cm distal to the GE junction to approximately 5cm caudally over the esophagus. The crura were reapproximated with simple interrupted sutures. The mucosa was inspected laparoscopically and endoscopically without any indication of injury. The endoscope was passed easily through to the gastrojejunal anastomosis. No complications were experienced in the operation. Esophagram was obtained on post-operative day 1, and no leak was identified. The patient was then started on clear liquid diet. The patient was discharged from the hospital on post-operative day 2.
Conclusion
The development of achalasia in patients who have already undergone laparoscopic roux-en-y gastric bypass has not been well described in the literature. Laparoscopic Heller myotomy provides a safe and effective option for these patients.
References
1.)Salvador R et al. Laparoscopic Heller Myotomy Can Be Used As Primary Therapy for Esophageal Achalasia Regardless of Age. J Gastrointest Surg 2013 [Epub AOP].
2.)Jaffin BW, Knoepflmacher P, Greenstein R. High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients. Obes Surg 1999; 9:390 –395.
3.)Kaufman JA et al. Laparoscopic Heller Myotomy and Roux-en-Y Gastric Bypass: A Novel Operation for the Obese Patient with Achalasia. J Laparoendosc Adv Surg Tech 2005; 15:391-395.
4.)Benavente-Chenhalls LA et al. Laparoscopic Heller Myotomy and gastric bypass for achalasia after vertical banded gastroplasty. Surg Obes Related Dis 2011; 7:664-665.
5.)Ramos AC et al. Achalasia and laparoscopic gastric bypass. Surg Obes Related Dis 2009; 5: 132-134.
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