Lutrzykowski M. BMI-2011, 1.5.3 (361-364) OA December 2011

Surgical treatment of morbidly obese patient with Achalasia

Marek Lutrzykowski, MD, Department of Surgery, Crittenton Hospital, Bloomfield Hills, MI 48302, USA

Received 2011.11.27 Accepted 2011.12.

Abstract

Combination of morbid obesity and achalasia (AC) is extremely rare. Patients with AC usually are complaining

of regurgitation, dysphagia to solids and liquids and weight loss. This is a disorder manifested by lacking of

motility of the esophagus and failure of relaxation of the lower esophageal sphincter (LES). This is a

presentation of a morbidly obese 32 year old patient diagnosed with AC at age nineteen. She was not

experiencing significant symptoms before planned DS because of recent Botox injection and dilatation. A few

months after an uneventful surgery patient developed dysphagia, nausea and vomiting after any oral intake and

underwent open transthoracic Heller esophagus-myotomy (EM) surgery.

Keywords: Morbid obesity; achalasia; transthoracic Heller; esophagus- myotomy; Duodenal switch

Marek Lutrzykowski, MD, Department of Surgery, Crittenton Hospital, Rochester MI, 10 West Square Lake Road. Suite 200. Bloomfield Hills, MI 48302, USA  [email protected]

Introduction repeated. The only successful treatment for achalasia is

esophago myotomy (EM) combined with concomitant anti

Achalasia (AC) is a rare esophageal motility disorder combined reflux procedure. This procedure can be done by laparoscopy with a lack of relaxation of the lower esophageal sphincter or open through abdomen or by thoracic approach. Morbid

(LES). Medical treatment of AC with calcium channel blockers obesity in patients with AC is very unusual. There are only a is unsuccessful and endoscopic procedures like dilatation or few articles written about concomitant surgical treatment of

Botox injections are usually short lasting and have to be obesity and achalasia. Laparoscopic EM combined with roux-

361 Lutrzykowski M. BMI-2011, 1.5.3 (361-364) OA December 2011 en-y gastric bypass (RNY-GBP) [1, 2] and two cases of open and eighteen months following surgery. She experienced no

DS combined EM [3]. In Duodenal Switch (DS) cases patients problems with dysphasia or regurgitation. Hyperlipidemia, did not have typical symptoms of AC before surgery like for arthritis and lower back pain had been cured. This patient had example dysphasia but had been diagnosed by routine pre- been followed for two and a half years. During this time BMI- operative upper GI study and three of them had manometric 21.25 and 105.88 of %excess weight loss (% EWL). Careful confirmation. In this case presentation patient with typical monitoring of patient’s nutritional status, vitamin levels and symptoms of AC for many years treated by dilatations and bone density was conducted during this time.

Botox injection underwent open DS. Few months later when Table # 1 is presents the progress of weight loss, BMI and % she developed severe dysphasia underwent open transthoracic EWL

Heller EM. Table 1

Time 0 3 months 6 months 12 ms 18 ms

Case Presentation Weight 122 kg 93 kg 75.8 kg 64.8 kg 63 kg

BMI 41.32 31.37 25.55 21.73 21.25 % EWL 52.41 83.06 102.74 105.88 A 32 year-old morbidly obese female BMI-41.32, had been seen and qualified for an open DS (ODS) procedure. Pre-operative Discussion diagnosis additionally to AC were hyperlipidemia, arthritis, lower back pain syndrome and gastro-esophageal reflux. Treatment of the morbidly obese patient with AC theoretically Because of severe dysphagia patient underwent multiple should concentrate on adding malabsorptive component to dilatations in the past and recent Botox injections weeks already existing restrictive component of AC. Theoretically in proceeding scheduled operation. Before surgery she was this situation malabsorptive part of DS should provide good almost symptoms free. In March 2005 she underwent an results. What was very interesting according to the patient’s uneventful ODS with appendectomy and cholecystectomy. statement after DS (but before Heller EM) she was not seeing Patient was released from the hospital on the third day any significant difference in amount of food she was eating following surgery. Two months after primary surgery in June before and after surgery despite the Gastric Sleeve. Patients 2005, patient developed severe dysphagia to solids and liquids. with AC discontinue eating not secondary to stomach dilatation In July of 2005 she underwent open transthoracic Heller EM. but esophageal distention and regurgitation. In my opinion, This approach has been chosen by the patient and a very the Gastric Sleeve (restrictive component) of DS should still be experienced thoracic surgeon from the University of Michigan. done because eventually these patients will require a Heller EM Transthoracic approach has been chosen to avoid more difficult and then the restrictive component will matter. Another abdominal access to avoid multiple heavy adhesions and question is raised about the best bariatric procedure for this potential injury to nearby organs. Since that time the patient type of patient. RNY-GBP is a restrictive procedure by itself; was doing very well. Her BMI-21 normalized between fifteen

362 Lutrzykowski M. BMI-2011, 1.5.3 (361-364) OA December 2011 whether adding another restriction below existing one should would consider DS to be the most suitable operation for obese make a big difference is questionable knowing that this patient patients with AC. very often lives on liquid high calorie diet. Performing simultaneous EM with a bariatric surgery seems to

Two articles about simultaneous laparoscopic Heller EM and be the most logical approach but in this case DS performed on

RNY-GBP have been published. Kaufman [2,3] in August asymptomatic patient followed by Heller EM added later

2005 a 25 year-old woman, BMI-58 lost 45 kg. to BMI- 42 and when patient became symptomatic worked for this patient very still remained morbidly obese. Follow up for this patient lasted well. Weight loss and alleviation of AC symptoms with this only 12 months and no further information about this patient approach were very successful. Whether concomitant Heller weight lost progress had been published. O’Rourke [4 ] was EM would be more beneficial requires further investigation regarding a 60 year-old woman BMI-52 with follow up for only and longer follow up. six months. This patient lost 45 kg in one year were available before RYN-GBP and EM and another 23 kg after a surgery. References

No further information about patient weight loss and final BMI 1. Kaufman JA, Pelligrini CA, Oeischlager BK. and AC were available . Laparoscopic Heller Myotomy and Roux-en-Y gastric

It has been proven that after Adjustable band placement there bypass: a novel operation for the obese patient with was a significant increase of LES resting pressure and at this achalasia. Journal of Laparoendoscopic & Advanced same time relaxation of LES decreased very often to pathologic Surgical Techniques. Part A. 15 (4)391-5, Aug. 2005 range. Additionally barium study showed significant dilation 2. O’Rourke R. Simultaneous surgical management of of the esophagus in 27% - 60% of the patient/ years after band achalasia and morbid. Obesity Surgery 2007 ; April placement. Significant dilatation represents severe motility 3. Herbella FA, Matone JL, Del Grande JC. Obesity and disorder which additionally would aggravate existing problems symptomatic achalasia. Obesity Surgery. May 2005; with patient’s AC. Another very important aspect of RNY-GBP 15 (5): 713-5, is issue of gastrojejunal stenosis and marginal ulcerations 4. Almogy G, Anthone GJ, Crookes PF. Achalasia in the which very often leads to stenosis. Stomal stenosis is the most context of morbid obesity: A rare but important common complication after RNY-GBP ranging from 3.1 – 14.4 association. Obesity Surgery. Dec. 2003; 13 (6): 896-

% and this unfortunate situation may significantly increase 900, symptoms of dysphagia. Gastric Sleeve operation performed 5. Richter J. Esophageal motility disorders. Lancet during DS does not disturb physiology of the stomach, the LES 2001; 358: 823-8. is intact, and vagal nerves are not transected, pylorus and 6. Jaffin BW, Knoepflmacher P, Greenstein R. High atrium are preserved and emptying of the sleeve is much faster Prevalence of asymptomatic esophageal motility than normal size stomach. Because of the above mentioned disorders among morbidly obese patients. Obesity reasons and significant malabsorptive component of DS I Surgery. 1999; 9: 390-5,

363 Lutrzykowski M. BMI-2011, 1.5.3 (361-364) OA December 2011

7. Stylopoulos N, Bunker CJ, Rattner DW. Development 13. Bloomston M, Durkin A, Boyce HW et al. Early

of achalasia secondary to Laparoscopic Nissen results laparoscopic Heller myotomy do not

fundoplication. Gastrointestinal Surgery, 2002; 6:P necessarily predict long-term outcome. The

368-78 American Journal of Surgery, 2004; 187: 403-407

8. Schwartz M, Raymond DL, Roiger RW et al. : Stenosis 14. Malthaner RA, Thomas RT, Miller L, Pearson FG.

of the gastroenterostomy after laparoscopic gastric Long term results in surgically managed esophageal

bypass. Obesity Surgery. 14 448-491 achalasia The Society of Thoracic Surgeons. 58

9. Go MR, Muscarella P, Needleman JB et al. :1343-1347

Endoscopic Management of stomal stenosis after 15. The American Journal of Surgery, 2000. 180 : 479-

Roux-en-Y gastric bypass. Surgery Endoscopy, 482

2004; 18 56-59 16. Catalano MF, Thomas Y, Rudic G. Endoscopic

10. Wilson JA, Romagnuolo J, Byrne KT et al. Predictors balloon dilation of stomal stenosis following gastric

of endoscopic findings after Roux-en-Y gastric bypass. bypass Obesity Surgery 17 298-303 2007

American Journal of Gastroenterology, 2006; 10 :

11. Weiss HG, Hermann N, Labeck B, et al. Treatment of Disclosures: The author has no commercial associations that

morbid obesity with laparoscopic adjustable gastric might be a conflict of interest in relation to this article.

2194-2198 Cover letter

12. Peternac D, Hauser R, Weber M, Schob O. The effects This article was not previously published, presented or is not

of laparoscopic adjustable gastric banding on the being submitted for publishing elsewhere. I claim no

proximal pouch and the esophagus Obesity Surgery, commercial associations that might be in a conflict of interest

2001. 11 : 76-86 banding affects esophageal motility. in relation to this article.

364