Achalasia after Bariatric Roux-en-Y Gastric Bypass Surgery Reversal

Abstract

Introduction: Achalasia is rare esophageal motility disorder that leads to loss of peristalsis in the distal esophagus and a failure of lower esophageal sphincter (LES) relaxation. It usually manifests as dysphagia for solids and liquids, and regurgitation of undigested food or saliva. The development of esophageal motility disorders including achalasia following bariatric surgery is still controversial and differ according to the type of surgery. Many cases of achalasia as a consequence of gastric band placement have been described. However, the development of achalasia and other motility disorders after Roux-en-Y gastric bypass (RYGB) are rare and only reported in some case reports. Case report: 70-year-old female patient with past medical history of morbid obesity presented to with complains of persistent nausea and regurgitation for the last 1 month. Her surgical history was significant for a laparoscopic cholecystectomy in addition to a laparoscopic Roux-en-Y gastric bypass (RYGB) approximately 2 years ago. Her surgery was revised 2 months prior to her presentation. Physical examination showed the wound of her recent surgery with no evidence of discharge or poor healing. Initial laboratory workup including complete blood count, comprehensive metabolic panel, and stool analysis were unremarkable. CT-scan of the abdomen and pelvis with contrast showed enteric contrast within the dilated distal esophagus, and was suspicious for mild stricture at gastro-esophageal sphincter (GES). Esophagogastroduodenoscopy showed a tortuous and dilated esophagus with large amounts of thick secretions. No strictures or stenosis was noted. Barium study was done afterward and showed persistent narrowing of the GES with a moderately dilated esophagus proximally and tertiary esophageal contractions. It was suggestive of achalasia. An outpatient manometry study revealed high LES pressure with abnormal relaxation, in addition to aperistalsis and those findings were consistent with type II achalasia. She was referred to surgery for possible laparoscopic heller's myotomy. Conclusion: We are presenting a rare case of achalasia after RYGB. As of our best knowledge there are only 3 cases reported for achalasia after RYGB and this is the first case described after revision of RYGB. The exact pathophysiology is not clearly understood, but local trauma due to surgery may play a role. An important consideration in similar cases is to rule out stenosis of the gastrojejunostomy.Figure 1Figure 2Figure 3