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Surgery for Obesity and Related Diseases ] (2014) 00–00
Case report
Laparoscopic Heller’s cardiomyotomy and Roux-En-Y gastric bypass for missed achalasia diagnosed after laparoscopic sleeve gastrectomy Han Boon Oh, M.B.B.S., M.R.C.S., Siau-Wei Tang, B.Med.Sci., B.M.B.S., M.R.C.S., Asim Shabbir, M.B.B.S., M.Med., F.R.C.S.Ed.*
Q1
University Surgical Cluster, National University Health System, Singapore Received January 10, 2014; accepted January 22, 2014
Keywords:
Achalasia; Obesity; Heller’s cardiomyotomy; Dysphagia; Bariatric surgery
Morbidly obese patients are increasingly being referred for bariatric surgery, which includes 3 common techniques: laparoscopic gastric banding (LAGB), Roux-en-Y gastric bypass (LRYGB) ,and sleeve gastrectomy (LSG). Esophageal dysmotility and disorders of the lower esophageal sphincter (LES) are also well documented in morbidly obese patients, with gastroesophageal reflux disease (GERD) being a common co-morbidity from low LES pressures [1]. Achalasia in morbidly obese patients has been reported to be 1%, and this group of patients tends to be asymptomatic or present with atypical symptoms [2]. However, achalasia arising after bariatric surgery is uncommon. To our knowledge, achalasia detected after LSG has not been previously reported. Case report The patient is a 39-year-old woman with a previous history of hepaticojejunostomy after a common bile duct injury during cholecystectomy complicated by an incisional hernia of the Kocher’s incision 11 years previously. She subsequently underwent LSG 3 years ago for morbid obesity with body mass index (BMI) of 49 kg/m2 and lost 30 kg. After the index weight loss surgery, she re-presented with progressive dysphagia over 1 year with reflux. She also experienced weight gain because of an increased intake of *
Correspondence: Dr. Asim Shabbir, University Surgical Cluster, NUHS, 1 E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore 119228. E-mail: [email protected]
2
high-calorie liquids and had a BMI of 38.3 kg/m . Gastrograffin swallow showed dilation of the esophagus from a distal stricture with trickle of contrast flowing into the stomach. A gastroscopy showed dilated mid-esophagus with residual food and liquids in the distal esophagus (Fig. 1). Magnetic retrograde cholangiopancreatography showed a grossly dilated esophagus (Fig. 2). The lower esophageal sphincter was tight and did not relax. Esophageal manometry was performed and showed a Type II achalasia. In view of her poor quality of life associated with failure of her LSG with weight gain, she was offered surgery with a secondary bariatric procedure. She subsequently underwent a laparoscopic Heller cardiomyotomy and RYGB with concurrent laparoscopic repair of her incisional hernia. The cardiomyotomy was performed from 7 cm in the distal esophagus to 3 cm into the stomach. A loop of jejunum was then identified 50-cm distal from the previous Roux-en-Y anastomosis, and a gastrojejunostomy was then performed. A mesh repair was then performed laparoscopically after the RYGB. There were no postoperative complications. She had relief of her dysphagia and an additional 17.5 kg weight loss, reaching a BMI of 31.5 kg/m2 6 months after the surgery. Discussion Achalasia is a rare disorder of esophageal motility and can be diagnosed by evidence of a lack of peristalsis and incomplete LES relaxation during swallowing. The prevalence of achalasia is rare in morbidly obese patients [3–5],
http://dx.doi.org/10.1016/j.soard.2014.01.023 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
F1 F2
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
2
91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145
W E B 4 C / F P O
H. B. Oh et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
Figure 1. Gastroscopy showing dilated mid- esophagus with residual food and liquids in the distal esophagus.
as patients with achalasia usually present with regurgitation, dysphagia, and weight loss rather than weight gain. Obese patients with achalasia present more commonly with respiratory symptoms rather than gastrointestinal symptoms. Therefore, it is less common for morbidly obese patients to report dysphagia as a presenting complaint of achalasia. In this case, dysphagia with solid food resulted in the patient taking in increased amount of high-calorie liquid foods to satisfy her satiety. The ideal surgery for a morbidly obese patient with achalasia is also a challenge for the bariatric surgeon [6,7]. The standard surgery for either pathology can result in worsening of either condition. There have been reports of simultaneous laparoscopic Heller myotomy and RYGB procedures that were successful in addressing both conditions, achieving weight loss, and symptomatic relief of achalasia [4,5].
There are also a few reports of achalasia diagnosed after bariatric surgery [8,9]. Most reported cases of postsurgery achalasia occurred after LAGB and these were treated with laparoscopic RYGB and Heller myotomy. Ramos et al. [10] and Chapman et al. [11] also separately reported achalasia that developed after RYGB. To our knowledge, this patient is the first case of achalasia to have been diagnosed after LSG. The data on the effect of LSG on LES pressure has been conflicting. Petersen [12] reported increases in LES pressures after LSG while both Braghetto et al. [13] and Kleidi et al. [14] reported a decrease in LES pressures after LSG. However, no cases of achalasia were reported after LSG despite the potential increase in LES pressures. In fact, Hagen et al. [7] utilized concurrent LSG and Heller myotomy to treat a case of achalasia with obesity. In our patient, there was no excess scar tissue at the gastroesophageal junction or strictures to cause stenosis. Preoperative manometry is not routinely performed for morbidly obese patients but has been recommended especially to look for functional disorders of esophageal dysmotility and LES to predict outcome for GERD [15]. Surgery for this group of patients targets first, the relief of symptomatic achalasia and second, to achieve weight loss. Our patient was offered surgery with the aim of improving her quality of life. Her dysphagia symptoms resolved and she achieved a gradual additional weight loss of 17.5 kg at 6 months. In addition, RYGB would prevent exposure of the lower esophagus to reflux, which was a real possibility if the remnant LSG tube was left behind. Conclusion Achalasia in the morbidly obese and presents more commonly with rather than dysphagia. Preoperative mended for all patients undergoing
Figure 2. MRCP showing grossly dilated esophagus.
patient is uncommon respiratory symptoms manometry is recombariatric surgery who
146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200
Heller’s Cardiomyotomy and RYGB / Surgery for Obesity and Related Diseases ] (2014) 00–00
Q3
201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226
present with symptoms of esophageal dysmotility. This select group of patients can potentially be treated successfully with surgery to relieve symptoms of achalasia and achieve weight loss via a combined approach of Heller myotomy and RYGB. Laparoscopic revisional surgery appears to be a safe option for this select group of patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Inter Med 2005;143:199–211. [2] Koppman JS, Poggi L, Szomstein S, Ukleja A, Botoman A, Rosenthal R. Esophageal motility disorders in the morbidly obese population. Surg Endosc 2007;21:761–4. [3] Almogy G, Anthone GJ, Crookes PF. Achalasia in the context of morbid obesity: a rare but important association. Obes Surg 2003;13: 896–900. [4] Kaufman JA, Pellegrini CA, Oelschlager BK. Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia. J Laparoendosc Adv Surg Tech A 2005;15:391–5. [5] O’Rourke RW, Jobe BA, Spight DH, Hunter JG. Simultaneous surgical management of achalasia and morbid obesity. Obes Surg 2007;17:547–9.
3
[6] Herbella FA, Matone J, Lourenco LG, Del Grande JC. Obesity and symptomatic achalasia. Obes Surg 2005;15:713–5. [7] Hagen ME, Sedrak M, Wagner OJ, Jacobsen G, Talamini M, Horgan S. Morbid obesity with achalasia: a surgical challenge. Obes Surg 2010;20:1456–8. [8] Cho M, Kaidar-Person O, Szomstein S, Rosenthal RJ. Achalasia after vertical banded gastroplasty for morbid obesity: a case report. Surg Laparosc Endosc Percutan Tech 2006;16:161–4. [9] Jomni T, Dray X, Merrouche M, Costil V, Vahedi K, Marteau P. Achalasia in an obese woman treated by laparoscopic gastric banding [in French]. Gastroenterol Clin Biol 2008;32:973–5. [10] Ramos AC, Murakami A, Lanzarini EG, Neto MG, Galvao M. Achalasia and laparoscopic gastric bypass. Surg Obes Relat Dis 2009;5:132–4. [11] Chapman R, Rotundo A, Carter N, George J, Jenkinson A, Adamo M. Laparoscopic Heller’s myotomy for achalasia after gastric bypass: a case report. Int J Surg Case Rep 2013;4:396–8. [12] Petersen WV, Meile T, Kuper MA, Zdichavsky M, Konigsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [13] Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20: 357–62. [14] Kleidi E, Theodorou D, Albanopoulos K, et al. The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized? Surg Endosc 2013;27:4625–30. [15] Klaus A, Weiss H. Is preoperative manometry in restrictive bariatric procedures necessary? Obes Surg 2008;18:1039–42.
227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252
Surgery for Obesity and Related Diseases ] (2014) 00–00
Case report
Laparoscopic Heller’s cardiomyotomy and Roux-En-Y gastric bypass for missed achalasia diagnosed after laparoscopic sleeve gastrectomy Han Boon Oh, M.B.B.S., M.R.C.S., Siau-Wei Tang, B.Med.Sci., B.M.B.S., M.R.C.S., Asim Shabbir, M.B.B.S., M.Med., F.R.C.S.Ed.*
Q1
University Surgical Cluster, National University Health System, Singapore Received January 10, 2014; accepted January 22, 2014
Keywords:
Achalasia; Obesity; Heller’s cardiomyotomy; Dysphagia; Bariatric surgery
Morbidly obese patients are increasingly being referred for bariatric surgery, which includes 3 common techniques: laparoscopic gastric banding (LAGB), Roux-en-Y gastric bypass (LRYGB) ,and sleeve gastrectomy (LSG). Esophageal dysmotility and disorders of the lower esophageal sphincter (LES) are also well documented in morbidly obese patients, with gastroesophageal reflux disease (GERD) being a common co-morbidity from low LES pressures [1]. Achalasia in morbidly obese patients has been reported to be 1%, and this group of patients tends to be asymptomatic or present with atypical symptoms [2]. However, achalasia arising after bariatric surgery is uncommon. To our knowledge, achalasia detected after LSG has not been previously reported. Case report The patient is a 39-year-old woman with a previous history of hepaticojejunostomy after a common bile duct injury during cholecystectomy complicated by an incisional hernia of the Kocher’s incision 11 years previously. She subsequently underwent LSG 3 years ago for morbid obesity with body mass index (BMI) of 49 kg/m2 and lost 30 kg. After the index weight loss surgery, she re-presented with progressive dysphagia over 1 year with reflux. She also experienced weight gain because of an increased intake of *
Correspondence: Dr. Asim Shabbir, University Surgical Cluster, NUHS, 1 E Kent Ridge Road, NUHS Tower Block, Level 8, Singapore 119228. E-mail: [email protected]
2
high-calorie liquids and had a BMI of 38.3 kg/m . Gastrograffin swallow showed dilation of the esophagus from a distal stricture with trickle of contrast flowing into the stomach. A gastroscopy showed dilated mid-esophagus with residual food and liquids in the distal esophagus (Fig. 1). Magnetic retrograde cholangiopancreatography showed a grossly dilated esophagus (Fig. 2). The lower esophageal sphincter was tight and did not relax. Esophageal manometry was performed and showed a Type II achalasia. In view of her poor quality of life associated with failure of her LSG with weight gain, she was offered surgery with a secondary bariatric procedure. She subsequently underwent a laparoscopic Heller cardiomyotomy and RYGB with concurrent laparoscopic repair of her incisional hernia. The cardiomyotomy was performed from 7 cm in the distal esophagus to 3 cm into the stomach. A loop of jejunum was then identified 50-cm distal from the previous Roux-en-Y anastomosis, and a gastrojejunostomy was then performed. A mesh repair was then performed laparoscopically after the RYGB. There were no postoperative complications. She had relief of her dysphagia and an additional 17.5 kg weight loss, reaching a BMI of 31.5 kg/m2 6 months after the surgery. Discussion Achalasia is a rare disorder of esophageal motility and can be diagnosed by evidence of a lack of peristalsis and incomplete LES relaxation during swallowing. The prevalence of achalasia is rare in morbidly obese patients [3–5],
http://dx.doi.org/10.1016/j.soard.2014.01.023 1550-7289/r 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.
F1 F2
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
2
91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145
W E B 4 C / F P O
H. B. Oh et al. / Surgery for Obesity and Related Diseases ] (2014) 00–00
Figure 1. Gastroscopy showing dilated mid- esophagus with residual food and liquids in the distal esophagus.
as patients with achalasia usually present with regurgitation, dysphagia, and weight loss rather than weight gain. Obese patients with achalasia present more commonly with respiratory symptoms rather than gastrointestinal symptoms. Therefore, it is less common for morbidly obese patients to report dysphagia as a presenting complaint of achalasia. In this case, dysphagia with solid food resulted in the patient taking in increased amount of high-calorie liquid foods to satisfy her satiety. The ideal surgery for a morbidly obese patient with achalasia is also a challenge for the bariatric surgeon [6,7]. The standard surgery for either pathology can result in worsening of either condition. There have been reports of simultaneous laparoscopic Heller myotomy and RYGB procedures that were successful in addressing both conditions, achieving weight loss, and symptomatic relief of achalasia [4,5].
There are also a few reports of achalasia diagnosed after bariatric surgery [8,9]. Most reported cases of postsurgery achalasia occurred after LAGB and these were treated with laparoscopic RYGB and Heller myotomy. Ramos et al. [10] and Chapman et al. [11] also separately reported achalasia that developed after RYGB. To our knowledge, this patient is the first case of achalasia to have been diagnosed after LSG. The data on the effect of LSG on LES pressure has been conflicting. Petersen [12] reported increases in LES pressures after LSG while both Braghetto et al. [13] and Kleidi et al. [14] reported a decrease in LES pressures after LSG. However, no cases of achalasia were reported after LSG despite the potential increase in LES pressures. In fact, Hagen et al. [7] utilized concurrent LSG and Heller myotomy to treat a case of achalasia with obesity. In our patient, there was no excess scar tissue at the gastroesophageal junction or strictures to cause stenosis. Preoperative manometry is not routinely performed for morbidly obese patients but has been recommended especially to look for functional disorders of esophageal dysmotility and LES to predict outcome for GERD [15]. Surgery for this group of patients targets first, the relief of symptomatic achalasia and second, to achieve weight loss. Our patient was offered surgery with the aim of improving her quality of life. Her dysphagia symptoms resolved and she achieved a gradual additional weight loss of 17.5 kg at 6 months. In addition, RYGB would prevent exposure of the lower esophagus to reflux, which was a real possibility if the remnant LSG tube was left behind. Conclusion Achalasia in the morbidly obese and presents more commonly with rather than dysphagia. Preoperative mended for all patients undergoing
Figure 2. MRCP showing grossly dilated esophagus.
patient is uncommon respiratory symptoms manometry is recombariatric surgery who
146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200
Heller’s Cardiomyotomy and RYGB / Surgery for Obesity and Related Diseases ] (2014) 00–00
Q3
201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226
present with symptoms of esophageal dysmotility. This select group of patients can potentially be treated successfully with surgery to relieve symptoms of achalasia and achieve weight loss via a combined approach of Heller myotomy and RYGB. Laparoscopic revisional surgery appears to be a safe option for this select group of patients. Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article. References [1] Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Ann Inter Med 2005;143:199–211. [2] Koppman JS, Poggi L, Szomstein S, Ukleja A, Botoman A, Rosenthal R. Esophageal motility disorders in the morbidly obese population. Surg Endosc 2007;21:761–4. [3] Almogy G, Anthone GJ, Crookes PF. Achalasia in the context of morbid obesity: a rare but important association. Obes Surg 2003;13: 896–900. [4] Kaufman JA, Pellegrini CA, Oelschlager BK. Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia. J Laparoendosc Adv Surg Tech A 2005;15:391–5. [5] O’Rourke RW, Jobe BA, Spight DH, Hunter JG. Simultaneous surgical management of achalasia and morbid obesity. Obes Surg 2007;17:547–9.
3
[6] Herbella FA, Matone J, Lourenco LG, Del Grande JC. Obesity and symptomatic achalasia. Obes Surg 2005;15:713–5. [7] Hagen ME, Sedrak M, Wagner OJ, Jacobsen G, Talamini M, Horgan S. Morbid obesity with achalasia: a surgical challenge. Obes Surg 2010;20:1456–8. [8] Cho M, Kaidar-Person O, Szomstein S, Rosenthal RJ. Achalasia after vertical banded gastroplasty for morbid obesity: a case report. Surg Laparosc Endosc Percutan Tech 2006;16:161–4. [9] Jomni T, Dray X, Merrouche M, Costil V, Vahedi K, Marteau P. Achalasia in an obese woman treated by laparoscopic gastric banding [in French]. Gastroenterol Clin Biol 2008;32:973–5. [10] Ramos AC, Murakami A, Lanzarini EG, Neto MG, Galvao M. Achalasia and laparoscopic gastric bypass. Surg Obes Relat Dis 2009;5:132–4. [11] Chapman R, Rotundo A, Carter N, George J, Jenkinson A, Adamo M. Laparoscopic Heller’s myotomy for achalasia after gastric bypass: a case report. Int J Surg Case Rep 2013;4:396–8. [12] Petersen WV, Meile T, Kuper MA, Zdichavsky M, Konigsrainer A, Schneider JH. Functional importance of laparoscopic sleeve gastrectomy for the lower esophageal sphincter in patients with morbid obesity. Obes Surg 2012;22:360–6. [13] Braghetto I, Lanzarini E, Korn O, Valladares H, Molina JC, Henriquez A. Manometric changes of the lower esophageal sphincter after sleeve gastrectomy in obese patients. Obes Surg 2010;20: 357–62. [14] Kleidi E, Theodorou D, Albanopoulos K, et al. The effect of laparoscopic sleeve gastrectomy on the antireflux mechanism: can it be minimized? Surg Endosc 2013;27:4625–30. [15] Klaus A, Weiss H. Is preoperative manometry in restrictive bariatric procedures necessary? Obes Surg 2008;18:1039–42.
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