Laparoscopic Heller myotomy after Roux-en-Y gastric bypass

Achalasia is a rare motility disorder of the esophagus and laparoscopic Heller myotomy (LHM) is the standard of care for symptom relief. The onset of achalasia in obese patients after Roux-en-Y gastric bypass (RYGB) is rare, the diagnosis is difficult, and the treatment is challenging.

We reviewed the hospital charts of a patient presenting with achalasia after RYGB. A review of the pertinent literature was performed.

A 51-year-old female was admitted to our department for a 10-month history of progressive dysphagia, regurgitation, and weight loss. She previously underwent laparoscopic RYGB for morbid obesity. The upper gastrointestinal endoscopy showed a dilated esophagus with increased resistance at the gastroesophageal junction. The barium swallow study revealed the classical “mouse-tail” appearance of the esophagogastric junction with delayed esophageal emptying. High-resolution manometry (HRM) was suggestive of a type II achalasia with esophageal body pan-pressurization. The patient underwent LHM. The overall operative time was 95 min and intraoperative blood loss was negligible. The postoperative course was uneventful and the patient was discharged on postoperative day 2. At 24-month follow-up, the patient has complete remission of symptoms.

Development of achalasia in obese patients after RYGB is rare. The presence of pathognomonic symptoms should always raise clinical suspicion, while HRM is essential to confirm the diagnosis. To date, there is no robust evidence for the more appropriate treatment of esophageal achalasia after RYGB. In these patients, LHM seems feasible, safe, and effective in symptom relief.