Achalasia after laparoscopic sleeve gastrectomy treated with peroral endoscopic myotomy

Abstract

Achalasia is a rare esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and abnormal peristalsis in the esophageal body. Patients may have dysphagia, chest pain, and regurgitation, which present a clinical challenge, and many patients were misdiagnosed as gastroesophageal reflux disease. Herein, we wish to report a case of a 34-year-old woman diagnosed with type I achalasia 5 years after undergoing laparoscopic sleeve gastrectomy (LSG).

The patient presented to our gastroenterology clinic with a 3-month history of progressive dysphagia to both solids and liquids, food regurgitation, chest pain, and postprandial vomiting, with an Eckardt score of 7. She had previously undergone LSG for morbid obesity 65 months prior to this visit. Her body weight decreased from 125.5 kg (body mass index [BMI] = 46.7) to 68.2 kg (BMI = 25.4) following the surgery. Notably, no obvious weight loss was found during the past 3 months despite dysphagia. Esophagogastroduodenoscopy revealed a dilated esophageal lumen with retained saliva, and a relatively tight and puckered LES (Figure 1A). Such findings remarkably differed from those observed 1 year before and 1 year after her bariatric surgery, including a non-dilated esophagus, relatively loose esophagogastric junction, and reflux esophagitis. Timed barium esophagram showed a dilated esophagus with delayed esophageal emptying. The barium column heights at 1, 2, and 5 min were 9.2, 4.1, and 3.1 cm, respectively, while the widths were 3.3, 3.1, and 3.1 cm, respectively (Figure 1B). High-resolution impedance manometry (HRIM) showed 100% failed contractions on wet swallows with a relatively high normal median LES-integrated relaxation pressure (IRP) of 18.5 mmHg (normal value <21 mmHg) (Figure 1C). Provocative test with 200-mL rapid drinking challenge further revealed panesophageal pressurization and hypertensive LES, which confirmed the diagnosis of type I achalasia based on Chicago Classification version 4.0. Endoscopic ultrasonography and CT scan showed no structural abnormalities or obstructive mass lesion at the gastroesophageal junction. Peroral endoscopic myotomy (POEM) was successfully performed (Figure 1D). Endoscopic muscle biopsies from the lower esophagus and gastroesophageal junction during POEM revealed typical smooth muscle proliferation without evident hypereosinophilia. Three months after the procedure, the patient reported symptom improvement with Eckardt score decreasing to 2, particularly dysphagia (dysphagia subscore decreasing from 3 to 1). Food regurgitation diminished. However, she continued to experience daily acid regurgitation and occasional chest pain (chest pain subscore of 1). Follow-up timed barium esophagram revealed no barium stasis, and HRIM revealed decreased LES IRP (0 mmHg) and resting pressure (4 mmHg). No panesophageal pressurization was observed during the rapid drinking challenge.

Development of achalasia in post-bariatric patients has been reported in a few case reports and retrospective studies. The pathogenesis remains elusive, and it is also challenging to distinguish patients with post-bariatric achalasia from those with idiopathic achalasia.^1-4 The predominant bariatric surgical procedures included open vertical banded gastroplasty, laparoscopic adjustable gastric banding, and Roux-en-Y gastric bypass, while LSG was observed in less than 10 cases.^{2, 4} Additionally, the majority of reported cases originated from Western countries with limited reports from Asian countries. Given the increasing prevalence of morbid obesity and growing popularity of bariatric surgery in Taiwan and worldwide, we emphasize the importance of awareness regarding the occurrence of achalasia after bariatric surgery. Furthermore, POEM appears to be a reliable and efficient procedure in this population just like in most other achalasia patients.⁵ Early diagnosis of achalasia and timely treatment may help to prevent the relentless progression to end-stage achalasia.

This study was supported by research grants from the National Taiwan University Hospital (NTUH 112-S0320) and the Ministry of Science and Technology (MOST 111-2314-B-002-189-MY3).

The authors declare no conflicts of interest.

Written informed consent was obtained from the patient.