Stephanie Manning, Dr1, Mark Smith, Mr2. 1Department of General Surgery, Hutt Hospital, New Zealand, 2Department of General Surgery, Dunedin Hospital, New Zealand
Introduction: The incidence of morbid obesity in the USA is increasing (38% of people over the age of 20 in 2014)(1), along with the rates of bariatric surgery. Achalasia itself is a rare entity, with an incidence of 1/million/year. The preferred surgery for achalasia is the Heller myotomy. Uncommonly, some patients can present with both morbid obesity and achalasia with a prevalence of 0.5-1% (2). There are several case reports of patients undergoing simultaneous laparoscopic achalasia and obesity procedures (2), but none of delayed surgery for obesity after Heller myotomy. This is technically challenging due to the take down of the anterior fundoplication and adhesions with an increased risk of oesophageal perforation (2). Similar surgery has been reported previously in three patients who had uncontrolled gastroesophageal reflux symptoms after Heller myotomy (3). In these patients, a small gastric pouch was made with a short limb Roux-en-Y byapss (RYGB). One of these was performed laparoscopically, the other two in the open fashion. One of these patients was obese and reported significant weight loss. We present a video of a laparoscopic RYGB for obesity in a 42 year old male who had undergone Heller myotomy with anterior partial fundoplication for achalasia six years previously. Although the Heller myotomy was successful in resolving the patient’s dysphagia, it allowed him to gain weight such that he presented with a BMI of 53 kg/m2 and type II diabetes.
Procedure: The operation was conducted using conventional laparoscopy in steep reverse Trendelenburg position. Extensive scarring and fibrotic tissue was encountered. The adhesions and previous fundoplication were taken down carefully using sharp scissor dissection. The myotomy was visualised following take down of the fundoplication and the scarred gastric fundus resected using a linear cutting stapler. A standard ante-colic, ante-gastric RYGB was then performed using a 100 cm alimentary limb and a 50 cm bilio-pancreatic limb.
Result: The patient initially made an uneventful post-operative recovery, however four months post-operatively developed dysphagia. Upper GI endoscopy showed a widely patent gastrojejunostomy but esophageal manometry confirmed recurrent achalasia. The patient is now awaiting balloon dilatation of the gastroesophageal junction.
Conclusions: Laparoscopic Roux-en-Y gastric bypass can be safely performed after previous surgery for achalasia despite considerable adhesions and scaring. In this case, the patient has had recurrence of achalasia which is difficult to determine if this is related to the known recurrence rate after Heller myotomy or to the RYGB.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86639
Program Number: V224
Presentation Session: Thursday Video Loop (Non CME)
Presentation Type: VideoLoop