Zeyad Loubnan, MD, Elissa Davila-Shiau, BA, Manish Parikh, MD, Akuezunkpa Ude Welcome, MD. NYU School of Medicine
This is a video of a 31 year old male with achalasia and severe obesity (Body Mass Index = 41). The patient reported a history of endoscopic balloon dilation 20 years prior and was having recurrent dysphagia. Manometry confirmed achalasia (aperistalsis, no relaxation and elevated LES pressure).
The patient underwent Robotic Heller Myotomy and a Roux-en-y gastric bypass (RYGB). The patient was placed in the supine position. Trocars were placed for the robotic technique. Hiatal dissection was performed. The vagi were identified and preserved. The gastroesophageal junction (GEJ) was identified. A longitudinal myotomy was initiated between the anterior and posterior vagus nerves at the 11:00 position, extending 6cm superiorly from the GEJ and 2-3cm distally. Repeat endoscopy was performed to confirm adequacy of the myotomy and air leak test was negative for mucosal injury.
Next an ante-colic, ante-gastric RYGB was performed with a 75 biliopancreatic limb and 150cm . The gastrojejunostomy was fashioned utilizing a 2-layer hand-sewn technique. The jejunojejunostomy was performed with a stapled technique and hand-sewn closure. The mesenteric defects were closed. The postoperative course was uneventful and the patient was discharged home post-op day #3.
Surgical management of the severely obese patient with achalasia is complex and the goal is to alleviate the dysphagia and to promote weight loss. Heller myotomy provides excellent relief of dysphagia and the Roux-en-Y gastric bypass provides excellent control of reflux as well as weight loss. We prefer RYGB to laparoscopic sleeve gastrectomy (LSG) due the potential of exacerbation of reflux after LSG.
We prefer to perform the myotomy first and then proceeding with the RYGB. The advantage of performing the myotomy first is that if the myotomy is difficult or if a perforation occurs, the surgeon has the option to perform a fundoplication and abort the RYGB. We prefer utilizing the hand-sewn technique for the gastrojejunostomy. An alternate option is the linear technique. The circular stapler technique (EEA) may be associated with difficulty in delivering the Orvil device due to the tortuous esophagus and potential mucosal disruption (if the myotomy has been performed first).
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94641
Program Number: V062
Presentation Session: Exhibit Hall Theater Video Session II
Presentation Type: EHVideo