Pseudoachalasia after Laparoscopic Adjustable Gastric Banding (LAGB)

Abstract

Purpose: We present the case of a 59-year-old female who underwent LAGB placement in 2009. The patient was losing weight as expected. Two years after the original surgery, she reported progressive dysphagia to solids and liquids with regurgitation. Barium swallow showed dilatation of the distal esophagus with moderate to severe concentric narrowing of the gastroesophageal (GE) junction. The band was seen at the level of GE junction on endoscopy. The band was deflated but the patient's symptoms continued. At this point an esophageal manometry was obtained and showed (see Figure 1). The band was removed with symptomatic improvement. Repeat manometry done 6 months later showed (see Figure 2). Obesity affects 90 million Americans and surgical management has considerably increased. LAGB is the most commonly performed procedure in the world. Esophageal dilation and dysmotility after LAGB is being increasingly recognized. Achalasia-like disorders (pseudoachalasia) with absence of esophageal peristalsis and impaired esophago-gastric junction (EGJ) relaxation can lead to symptomatic dysphagia necessitating band removal.The interval between band placement and onset of symptoms is variable. The question of pre-existing dysmotility and benefit of performing esophageal manometry prior to band placement remains controversial. In our patient a pseudoachalasia like picture developed from the band and the condition reversed partially once the band was removed. In conclusion, severe motility disorders mimicking achalasia are encountered in patients with esophageal symptoms after LAGB. Therefore, in LAGB patients with symptoms, an esophagram should be obtained to rule out band slippage. In the absence of such abnormalities, an esophageal manometry is useful to detect motility disorders. It then provides strong arguments in favor of band removal, given the severe but reversible character of this motility disorder.Figure: [591]Figure: [591]