|Home | About | Journals | Submit | Contact Us | Français|
Disorders of the oesophagus have been linked to surgical bariatric procedures and obesity. However the relationship between achalasia and gastric bypass is not clearly understood and has only recently been reported following gastric bypass.
We present the case of a 53-year-old woman who re-presented following a gastric bypass with a new diagnosis of achalasia. This was treated successfully with laparoscopic Heller's Myotomy with discharge from hospital 10 days post operatively.
It is not clear whether achalasia is a complication of gastric bypass procedures. This is only the second reported case of the condition developing after this operation. The mechanism by which it may develop is yet to be clearly established.
This case highlights the need to investigate further a possible link between achalasia and gastric bypass and to manage susceptible patients accordingly in the pre-operative stage.
In line with the growing epidemic of obesity and related diseases, bariatric surgery has become a treatment option in patients with BMI above 40 kg/m2 (or above 35 kg/m2 with other comorbidities) where conservative treatment has failed to achieve the necessary weight loss.1 Three techniques are commonly used; gastric banding, gastric bypass, and sleeve gastrectomy.1 Oesophageal dilatation is a potential complication of these procedures and pseudo-achalasia has been reported as a response to gastric banding.1 In addition there is a high prevalence of oesophageal dysmotility disorders in the morbidly obese, one study reporting a 1% prevalence of achalasia.2
Achalasia is a relatively rare disease in which neurodegeneration leads to dysfunction of the lower oesophageal sphincter (LOS) and abnormal peristalsis of the oesphagus.3 There have been few reports of achalasia appearing after bariatric surgery. Khan et al. found a reversible pseudo-achalasia after gastric banding.4 Awad et al. found a pseudoachalasia following a Teflon gastric wrap performed for morbidity obesity.5
We present a case of achalasia appearing after a laparoscopic gastric bypass procedure, only the second reported to our knowledge.
A 53-year old woman was referred to our unit in 2011 with weight re-gain following an open gastric bypass, performed in 2006 in Belgium. 2 years after surgery she started to develop episodes of severe epigastric pain radiating to the left upper quadrant and symptoms of acid reflux. Past medical history included hypertension, diabetes, depression and bipolar disorder.
An endoscopy demonstrated a dilated oesophagus, oesophagitis and ulceration above the oesophago-gastric junction. A barium swallow revealed that the thoracic oesophagus was markedly dilated with reduced efficiency of the primary peristaltic stripping wave, and contrast was slow to pass through the gastro-oesophageal junction (Fig. 1). High-resolution oesophageal manometry (HRM) demonstrated oesophageal aperistalsis and absence of lower oesophageal sphincter relaxation, diagnostic of achalasia (Fig. 2). Moreover the impedance activity was grossly decreased suggesting a dilated oesophagus, supporting the diagnosis.
The different treatment options (endoscopic or surgical) were discussed with the patient and the decision was taken to perform a laparoscopic Heller's Myotomy. There were extensive adhesions, particularly at the cardia, related to the previous open gastric bypass. Careful adhesiolysis was performed and the anatomy confirmed. A Heller's cardiomyotomy was performed using a Harmonic scalpel to dissect distally and a hook diathermy for proximal dissection. An iatrogenic hole in the mucosa was identified during the myotomy. This was closed with intracorporeal sutures and placement of an omental patch. An anterior fundoplication of the stomach remnant was considered but not performed, as the risk of significant reflux was minimal due to the presence of the gastric bypass. The myotomy was continued for 4 cm proximal to the lower oesophageal sphincter and 5 cm distally. Complete myotomy was confirmed by intraoperative endoscopy.
Post-operatively the patient recovered well and a follow-up gastrografin swallow revealed no leak of contrast during its passage through the oesophagus. The patient had an episode of chest pain with raised inflammatory markers, and so a Computerised Tomography (CT) scan was arranged. This identified pulmonary atelectasis but no leak or intra-abdominal collections. She was treated with a short course of antibiotics and discharged 10 days post-operatively.
It is established that there is a relationship between obesity and oesophageal motility disorders.2 However the relationship between achalasia and bariatric surgery is less well understood. In this case it was difficult to determine whether achalasia had developed de-novo, and independent of surgery, or as a consequence of the gastric bypass.
There is some evidence that gastric bypass may increase the chance of developing achalasia. Ramos et al. describe a case in which achalasia appeared 4 years after gastric bypass where surgery may have caused the disease to progress.6 The development of achalasia after surgery on the foregut is more common. Shah et al. report that 25% of patients diagnosed with achalasia had a history of surgery or trauma to the chest or foregut, compared to 9.5% of patients with dysphagia and normal manometry.7 The theory postulated was that trauma might result in vagal disruption leading to nerve dysfunction and the development of achalasia.7 The mechanism of damage may not be the same as vagal transection.7 There is also evidence of an indirect effect on LOS pressure by gastric bypass. The vagotomy to the stomach remnant including the antrum leads to decreased postprandial gastrin levels.8 This in turn will have an effect on the LOS, increasing its resting tone, although not to the levels seen in classical achalasia.9
Obesity alone contributes to a number of diseases that threaten the health of an increasing number of people in the western world. Pseudo-achalaisa after gastric banding is a well-known complication of this procedure and is a cause for concern amongst many bariatric surgeons. However following gastric bypass, despite dysphagia being common the diagnosis of achalasia remains rare. This is only the second published case of achalasia developing following a gastric bypass. Further evidence is needed to establish if there is a higher risk of developing achalasia following this procedure. If so, high-resolution oesophageal manometry is advocated in the routine preoperative investigation of any patient being considered for bariatric surgery with symptoms of oesophageal dysmotility.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Adrianna Rotundo: Clinical care of patient and revision of manuscript; Andrew Jenkinson: Clinical care of patient and revision of manuscript; Jason George: Revision of manuscript; Nick Carter: Revision of manuscript; Marco Adamo: Revision of manuscript; Rhiannon Chapman: Clinical care of patient and author of manuscript.