Journal of Obesity & Weight Loss Therapy
Open Access

Achalasia is an esophageal motility disorder characterized by absence of esophagealperistalsis and failure of the lower esophageal sphincter (LES) to relax during swallowing [1].Prevalence of achalasia in the general population is around 10 cases per 100,000 individuals [2].Even when studies report a higher prevalence of esophageal motility disorders in obese patientscompared to cohorts with normal body mass index, achalasia and morbid obesity are twoconditions that do not classically occur together [3,4]. For this reason, there are no establishedsurgical guidelines as to the treatment for patients who present with achalasia and morbidobesity. It is well known that Laparoscopic Heller Myotomy (LHM) and partial fundoplication isthe standard surgical approach for achalasia in non-obese population [5]. There is also evidencethat bariatric surgery is the most effective treatment for morbid obesity; being sleevegastrectomy and Roux-en-Y gastric bypass (RYGB) the most frequently performed bariatricoperations [6]. However, there is little information regarding how to treat achalasia after bariatricsurgery. Cases of achalasia treatment after RYGB have been described in literature, but there isscarce information about treating achalasia after sleeve gastrectomy.

We present the case of a 41-year-old female patient who presented to the emergencydepartment with chief complaint of persistent dysphagia to solids and liquids. The patient had ahistory of morbid obesity and had undergone Laparoscopic Sleeve Gastrectomy (LSG) in 2018,at an outside institution. She reported having dysphagia to solids and liquids since her earlytwenties,but had not been evaluated previously for this complaint. Our patient also reportedepisodes of post-prandial nausea and vomiting with associated epigastric discomfort. She alsohad a surgical history of abdominoplasty and bilateral breast implants performed a few monthsafter LSG. There were no significant findings on physical exam.

Preoperatively, contrast esophagogram demonstrated a standing column of oral contrastat the distal esophagus secondary to either a tight stenosis or beaking (Figure 1). An upperendoscopy was performed and revealed a dilated esophagus. The scope was advanced into thestomach without stricture or mucosal lesions identified. On manometry, elevated resting LESpressures were reported with absent relaxation during swallowing. It also revealed esophagealbody aperistalsis with esophageal pressurization, consistent with Type 2 achalasia.

Figure 1: Pre-op UGIS demonstrating tight stricture/stenosis at the gastroesophageal junction with minimal passage of contrast to gastric remnant.

After the above findings, the patient was scheduled for Laparoscopic Heller myotomy at ourinstitution. Upon entering the abdominal cavity via laparoscopy, paraesophageal membranes andadhesions from previous surgery were dissected. Gastroesophageal (GE) fat pad removed forbetter GE junction visualization, and distal mediastinal esophagus mobilized into the abdomen.

Heller myotomy was performed anteriorly, 5cm cephalad and 3cm caudal to GE junction,making sure that complete division of circular muscle fibers was done. Intraoperative endoscopywas performed to confirm adequate muscle division and no air leak. Upper GI series performedon postoperative day one showed slow esophageal emptying through smooth tapered narroweddistal esophagus and no evidence of leakage. There were no postoperative complications and thepatient was discharged on postoperative day two, tolerating liquid diet. Patient has been followedfor six months after surgery and no postoperative complications have been reported. Duringfollow up, Eckardt Symptom Score (ESS) has been used for post-surgical outcome evaluation.At six months after surgery, patient has maintained stable weight, reports only occasional chestpain and dysphagia, and denies any regurgitation episodes, corresponding to ESS of 2/12.

There have been few cases of achalasia after bariatric surgery described in the literature,where most cases have been after RYGB. Masrur et al. described the first Robotic Hellermyotomy for achalasia after Laparoscopic RYGB with successful results [7]. Similarly, Bouleset al. reported eight patients who underwent Heller Myotomy (HM) to treat achalasia diagnosedafter RYGB. Six of the eight patients who underwent HM achieved resolution of achalasiasymptoms at a mean time of 1.6 months and remained asymptomatic for the total follow-up of 36months [8]. Casas et al. reached similar conclusions, indicating that LHM is an effective and safetherapy in patients with RYGB anatomy and achalasia [9].

While most of the cases in literature report patients treated for achalasia after bariatricsurgery, Ramos et al. suggested that morbidly obese patients with achalasia, should be treated forboth diseases during a single surgery [10]. Fisichella and colleagues suggested a concomitantLHM and laparoscopic RYGB as an approach that can provide excellent relief of symptoms andadequate control of reflux while promoting weight loss in obese patients with achalasia [11]. Incontrast, Crafts et al. concluded that patients who undergo surgical intervention for achalasiabefore having bariatric surgery tend to have better outcomes compared to those where achalasiais treated after bariatric surgery [12].

There have been only two cases reported in the literature of patients treated surgically forachalasia diagnosed after undergoing LSG, which were addressed in the systematic review ofCrafts et al. One of the patients was treated with LHM and conversion to RYGB, with initialimprovement of dysphagia that later recurred, and gradual weight loss of 17.5 kg in 6 months[12,13]. The second case involved a patient treated with LHM alone, but never achieved clinicalremission postoperatively and was later diagnosed with gastric stenosis requiring endoscopicdilation [12]. In the latter, it is difficult to evaluate the outcome of LHM, given the presence ofan additional pathology (gastric stenosis), which could have been responsible for the patient’sinitial clinical presentation and symptoms.

Our patient’s follow up included evaluation of symptoms six months after surgery usingEckardt Symptoms Score (ESS). ESS is widely used in both clinical and research settings as agold standard for measuring achalasia symptom severity [14]. It consists of a self-report scaleevaluating weight loss, dysphagia, chest pain and regurgitation, in which patient grades eachitem from 0 to 3 according to frequency. A patient is considered to be in clinical remission ifhe/she is assigned to be a stage 0-I or having less than three points out of twelve [15].

To our knowledge, this would be the first case described in the literature of a patient whoachieved clinical remission after undergoing LHM to treat achalasia diagnosed after LSG.

However, our patient’s history of dysphagia prior to bariatric surgery raises the suspicion of nondiagnosedachalasia prior LSG. This case highlights the importance of esophageal testing beforebariatric procedures in patients with esophageal dysmotility symptoms. Also, despite our patienthaving remained on clinical remission after 6 months of intervention, further comparative studiesneed to be performed before establishing clear guidelines to manage patients diagnosed withachalasia after bariatric surgery

We present a case of a patient diagnosed with achalasia after LSG, who was successfullytreated with LHM. Despite there being no consensus regarding the gold standard to treatachalasia after bariatric surgery, LHM seems to be a reasonable surgical option to treat achalasiaafter LSG. In selected patients, LHM can lead to resolution of dysphagia without adding otherwell known complications associated with RYGB.