Gabriel Arevalo, MD, Joslyn Jose, MD, Leena Khaitan, MD, Jeffrey Marks, MDFACSFAGS. UH Cleveland Medical Center
Nausea and vomiting are common sequelae following bariatric procedures and RNYGB is no exception. Differential diagnoses of postoperative complications that can elicit these symptoms include obstruction, hematoma, postoperative edema, internal hernia, intussusception, anastomotic strictures, gallstone formations and marginal ulcers.
If an etiology remains unknown, one must think of the development of an esophageal motility disorder in the obese patient. Achalasia, a rare motility disorder in the general population, is even more infrequent in association with morbid obesity (.5-1%).
The challenge in the approach to a morbidly obese patient with achalasia is related to its atypical presentation. It can range from asymptomatic to common symptoms that correlate with obesity itself, leading to misdiagnoses.
This video presents the case of a 60 year-old woman with a history of intractable nausea & emesis after RNYGB. She had multiple endoscopic interventions and a laparoscopic cholecystectomy, none of which improved her symptoms, which eventually required a feeding tube to be placed. She was referred to our clinic 6 months later for further workup of her history of reported dysphagia. Esophageal manometry and impedance testing were performed, revealing elevated lower esophageal sphincter pressure and integrated relaxation pressure, with increased pressurization of the esophagus and weak simultaneous contraction in the esophageal body. A diagnosis of type 2 achalasia was made based on these results. A Peroral Endoscopic Myotomy (POEM) procedure was performed. The challenge of the procedure is determining the extent of the myotomy in the cardia compounded with the inability to retroflex the scope in the small gastric pouch. This video demonstrates the landmarks of the GEJ and cardia inside the mucosal tunnel that can aid in the extension of dissection during the myotomy. To date there are only two cases reported describing per oral endoscopic myotomy (POEM) after RNYGB .
The early diagnosis of achalasia makes this case unique. Dysmotility of the esophagus is rare but real in the obese population. A detailed history remains an important tool for the surgeon, along with awareness of atypical symptoms that should raise the suspicion of achalasia pre and postoperatively.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87540
Program Number: V142
Presentation Session: Flexible Endoscopy Videos Session
Presentation Type: Video