Simultaneous surgical treatment of morbid obesity and end-stage achalasia: a case report and review of literature

Background End-stage achalasia is a challenging condition to deal with, due to severely impaired esophageal function. Laparoscopic Heller-Dor with pull-down technique improves the outcomes of these patients. Some patients with end-stage achalasia also suffer from severe obesity, thus requiring surgical treatment for both conditions. We report on a patient with severe obesity and an end-stage achalasia treated with pull-down laparoscopic myotomy in combination with Roux-en-Y gastric bypass (RYGB). Case presentation A 42-year-old male with end-stage achalasia and severe obesity (kg 148, BMI 42.3 kg/m 2 ) was proposed to the multidisciplinary group. Pre-operative assessment included symptom score, upper GI endoscopy, barium-swallow, high-resolution manometry (HRM), multidisciplinary bariatric evaluation. Two surgical teams with extensive experience in upper-GI and bariatric surgery were involved to plan the surgical treatment. The laparoscopic approach was carried out successfully without intraoperative complications. Firstly, approximately 10 cm of the lower mediastinal esophagus were isolated and pulled down into the abdomen. The esophagus was fixed to the crura with two non-absorbable stitches on each side, followed by an extensive Heller-myotomy. Then, a standard RYGB was carried out (100 cm alimentary- and BP-limb length). Gastrografin® x-ray was performed on POD 1, showing the verticalization of the organ's axis and the correct progression of the contrast through the anastomoses. The patient started a soft diet and was discharged on POD 4. At 6-months follow-up, the patient underwent HRM and 24h-pH monitoring showing a normal IRP and distal esophageal acid exposure. The symptom score was decreased to normal value and BMI was 31.5 kg/m 2 . Conclusion To our knowledge, this is the first reported case of a combined approach to address end-stage achalasia and severe obesity with well-established and standardized operations. It proved to be feasible and effective to treat both clinical conditions. Further and formally designed studies are needed to confirm these results.