Laparoscopic Heller myotomy and Roux-en-Y gastric bypass: a novel operation for the obese patient with achalasia

Surgical approaches for achalasia and obesity: a systematic review and patient-level meta-analysis

PURPOSE

Synchronous and metachronous presentations of achalasia and obesity are increasingly common. There is limited data to guide the combined or staged surgical approaches to these conditions.

METHODS

A systematic review (MEDLINE, Embase, and Web of Science) and patient-level meta-analysis of published cases were performed to examine the most effective surgical approach for patients with synchronous or metachronous presentations of achalasia and obesity.

RESULTS

Thirty-three studies with 93 patients were reviewed. Eighteen patients underwent concurrent achalasia and bariatric surgery, with the most common (n = 12, 72.2%) being laparoscopic Heller's myotomy (LHM) and Roux-en-Y gastric bypass (RYGB). This combination achieved 68.9% excess weight loss and 100% remission of achalasia (mean follow-up: 3 years). Seven (6 RYGB, 1 biliopancreatic diversion) patients had bariatric surgery following achalasia surgery. Of these, all 6 RYGBs had satisfactory bariatric outcomes, with complete remission of their achalasia (mean follow-up: 1.8 years). Sixty-eight patients underwent myotomy following bariatric surgery; the majority (n = 55, 80.9%) were following RYGB. In this scenario, per-oral endoscopic myotomy (POEM) achieved higher treatment success than LHM (n = 33 of 35, 94.3% vs. n = 14 of 20, 70.0%, p = 0.021). Moreover, conversion to RYGB following a restrictive bariatric procedure during achalasia surgery was also associated with higher achalasia treatment success.

CONCLUSION

In patients with concurrent achalasia and obesity, LHM and RYGB achieved good outcomes for both pathologies. For those with weight gain post-achalasia surgery, RYGB provided satisfactory weight loss, without adversely affecting achalasia symptoms. For those with achalasia after bariatric surgery, POEM and conversion to RYGB produced greater treatment success.

Mediastinoscopy-assisted Transhiatal Esophagectomy (MATHE) in End-stage Achalasia and Gastric Bypass: Technique and Early Results

INTRODUCTION

Approximately 5% of patients who have undergone prior Heller myotomy and Roux en Y gastric bypass progress to end-stage achalasia (ESA). Surgical options for ESA are often limited to esophagectomy for management of severe dysphagia or life-threatening aspiration episodes. Mediastinoscopy-assisted transhiatal esophagectomy (MATHE) by a small left neck incision combined with an abdominal incision, without using a transthoracic approach, has been reported to reduce pulmonary complications. We herein present the first report of MATHE in 2 consecutive patients with ESA and gastric bypass.

MATERIALS AND METHODS

Between August 2017 and September 2020, 2 patients who had undergone Heller myotomy and Roux en Y gastric bypass underwent MATHE for ESA. Transhiatal esophagectomy with mediastinoscopy-assisted dissection was performed. The remnant stomach was used as the conduit in both cases. The embedded Supplemental Digital Content 1 (http://links.lww.com/SLE/A269) reports our novel technique.

RESULTS

Both cases were completed laparoscopically without conversion to laparotomy or thoracotomy. Median length of hospital stay was 9 days (range, 6 to 11 d). Postoperatively, 1 patient developed a cervical anastomotic leak, which healed with conservative management. No other major complications were observed.

CONCLUSIONS

MATHE can be safely performed in patients with a history of gastric bypass and ESA without requiring thoracoscopic mobilization of the esophagus. Further studies are required to validate reproducibility of our technique as an alternative to using a thoracic incision.

Treatment of achalasia in the bariatric surgery population: a systematic review and single-institution experience

BACKGROUND

Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5-1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain.

METHODS

Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response.

RESULTS

Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy.

CONCLUSIONS

Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.

The Malnutrition Universal Screening Tool can predict malnutrition in patients with esophageal achalasia

BACKGROUND

At present, little research has been done to clarify why some achalasia patients do not lose weight or are even obese and to investigate their nutritional status. The aim of this study was to identify predictive factors of malnutrition in these patients and to assess their response to treatment.

METHODS

We conducted a retrospective cohort study on consecutive patients referred to a tertiary-care center for laparoscopic or endoscopic treatment of achalasia. Demographics, anthropometric variables, presenting symptoms, and results of the objective investigation were recorded on a prospectively collected database. The severity of symptoms and the nutritional risk were assessed by the Eckardt score and the Malnutrition Universal Screening Tool (MUST), respectively, before and after treatment.

RESULTS

Between 2013 and 2019, 171 patients met the study inclusion criteria. There were 87 (50.9%) male and the median age was 53.0 (39-66) years. The median Eckardt score was 6 (interquartile range 3). Based on the MUST score, 121 (70.8%) patients were classified at moderate/high risk of malnutrition. Of these, 93 (76.9%) were overweight or obese. Compared to low-risk group, predictive factors of moderate/high risk of malnutrition were higher Eckardt score [odds ratio (OR) 1.63; 95% CI, 1.35-1.99], more severe dysphagia (OR 2.68, 95% CI, 1.66-4.30), and greater absolute weight loss (OR 2.37; 95% CI, 1.77-3.17). The latter was the only independent predictive factor of malnutrition (OR 2.54; 95% CI, 1.69-3.82). After treatment, the measured MUST score was 0 in 96% of patients.

CONCLUSIONS

Over 70% of achalasia patients were at moderate/high risk of malnutrition. These individuals may benefit from a perioperative multidisciplinary approach including dietary intervention to stabilize weight and improve their nutritional status.

Achalasia and obesity: patient outcomes and impressions following laparoscopic Heller myotomy and Dor fundoplication

PURPOSE

The optimal management of achalasia in obese patients is unclear. For those who have undergone Heller myotomy and fundoplication, the long-term outcomes and their impressions following surgery are largely unknown.

METHODS

A retrospective review of patients who underwent laparoscopic Heller myotomy and Dor fundoplication (LHMDF) for achalasia was performed. From this cohort, Class 2 and 3 obese (BMI > 35 kg/m²) patients were identified for short- and long-term outcome analysis.

RESULTS

Between 2003 and 2015, 252 patients underwent LHMDF for achalasia, and 17 (7%) patients had BMI > 35 kg/m². Pre-operative Eckardt scores varied from 2 to 9, and at short-term (2-4 week) follow-up, scores were 0 or 1. Ten (58%) patients had available long-term (2-144 months) follow-up data. Eckardt scores at this time ranged from 0 to 6. Symptom recurrence was worse for patients with BMI > 40 kg/m² compared to patients with BMI < 40 kg/m². BMI was largely unchanged at long-term follow-up regardless of pre-intervention BMI. Most patients were satisfied with surgery but would have considered a combined LHMDF and weight-loss procedure had it been offered.

CONCLUSION

LHMDF for achalasia in obese patients is safe and effective in the short term. At long-term follow-up, many patients had symptom recurrence and experienced minimal weight loss. Discussing weight-loss surgery at the time LHMDF may be appropriate to ensure long-term achalasia symptom relief.

Laparoscopic Heller Myotomy and Roux-en-Y Gastric Bypass as Treatment for Patients with Achalasia and Morbid Obesity: Outcomes in a Short Series of Patients

Background: The association between morbid obesity and esophageal achalasia is very infrequent. However, over the last decade, these cases started to increase because of the disturbing rise of morbid obesity worldwide. Heller myotomy (HM) and laparoscopic fundoplication represent the best treatment option for esophageal achalasia. However, in morbidly obese patients with achalasia, the best treatment option is not established. We present laparoscopic HM and Roux-en-Y gastric bypass (RYGB) as an alternative treatment for morbidly obese patients with achalasia. Materials and Methods: We analyzed the course of patients with achalasia and morbid obesity in our institution undergoing a laparoscopic HM and RYGB, with at least 1 year of follow-up. Symptoms questionnaire, body mass index (BMI), and minuted esophagogram before and after treatment were performed in all patients. Results: Seven patients underwent laparoscopic HM and RYGB. All patients had dysphagia. The mean BMI before the onset of symptoms was 42 kg/m² (range 40 to 50). In 5 patients, preoperative contrast esophagram showed mild or marked dilated esophagus, and in 2, one esophageal curve and severe dilation. Manometry confirmed the diagnosis. At a mean follow-up of 38 months (range 14-69), all patients reported a marked improvement in dysphagia, with median overall satisfaction rating of 10 (range 9-10), and no symptom of gastroesophageal reflux disease (GERD). The mean percentage excess weight loss (%EWL) was 77.1% (range 70.1-98.1) and the mean BMI was 25.7 kg/m² (range 23-31). Conclusion: HM and RYGB are an excellent treatment for morbidly obese patients with achalasia. All patients reported a marked improvement of their dysphagia and no symptoms of GERD. The %EWL and BMI descent was very good and maintained through time, showing also an excellent control for morbid obesity.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia

BACKGROUND

Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia.

METHODS

Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups.

RESULTS

A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79).

CONCLUSIONS

POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

The Treatment of Achalasia in Obese Patients

Epidemiological studies have demonstrated that obesity is frequently associated with esophageal motility disorders. Morbid obesity and achalasia may coexist in the same patient. The management of the morbidly obese patient with achalasia is complex and the most effective treatment remains controversial. The aim of this study is to review the pathophysiology, clinical presentation, diagnostic evaluation, and treatment of achalasia in morbidly obese patients. Evidence Review: PubMed search from January 1990 to July 2017, including the following terms: achalasia, morbid obesity, bariatric, and treatment. Achalasia in the setting of morbid obesity may be successfully treated by endoscopic or surgical methods. Surgeons may choose to add a bariatric procedure, with various strategies present in the literature. A review of the present literature suggests that the preferred approach to achalasia in the morbidly obese patient is to address both disease processes simultaneously with a laparoscopic Heller myotomy and a Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is cited by most experts as the bariatric procedure of choice, given its antireflux benefits. A well-powered study, comparing the various approaches to the treatment of achalasia in the setting of morbid obesity, is required to establish a consensus.

Achalasia after bariatric Roux-en-Y gastric bypass surgery reversal

Achalasia is a rare esophageal motility disorder that is characterized by a loss of peristalsis in the distal esophagus and failure of lower esophageal sphincter relaxation. The risk of developing esophageal motility disorders, including achalasia, following bariatric surgery is controversial and differs based on the type of surgery. Most of the reported cases occurred with laparoscopic adjustable gastric banding. To our knowledge, there are only three reported cases of achalasia after Roux-en-Y gastric bypass and no reported cases after revision of the surgery. We present a case of a 70-year-old female who had a previous history of Roux-en-Y gastric bypass with revision. She presented with persistent nausea and regurgitation for one month. Esophagogastroduodenoscopy showed a dilated esophagus without strictures or stenosis. A barium study was performed after the endoscopy and was suggestive of achalasia. Those findings were confirmed by a manometry. The patient was referred for laparoscopic Heller’s myotomy.

The surgical management of achalasia in the morbid obese patient

INTRODUCTION

Morbid obesity and achalasia may coexist in the same patient. The surgical management of the morbidly obese patient with achalasia is complex, and the most effective treatment still remains controversial. The goal of our report is to provide our evidence-based approach for the surgical management of the patient with achalasia and morbid obesity.

RESULTS

Three main surgical approaches have been used for the concomitant treatment of morbid obesity and achalasia: 1) a laparoscopic Heller myotomy and a laparoscopic Roux-en-Y gastric bypass (LRYGB); 2) a laparoscopic Heller myotomy with bilio-pancreatic diversion; and 3) a laparoscopic Heller myotomy with a sleeve gastrectomy. Our approach of choice is the first one discussed, that is the laparoscopic Heller myotomy with a LRYGB, as this approach can provide excellent relief of symptoms and control of reflux while at the same time treating obesity and its comorbidities.

CONCLUSIONS

Achalasia and obesity can coexist, albeit infrequently. A laparoscopic Heller myotomy with a LRYGB allows the simultaneous treatment of both diseases. When a morbidly obese patient with achalasia chooses to have a myotomy alone and not a LRYGB, a thorough discussion of the risks and benefits should occur and the autonomy of the patient's decision-making should be respected.

Robotic heller myotomy and Dor fundoplication for achalasia in a woman with morbid obesity

Achalasia is a relatively rare condition with a prevalence estimated at less than 0.001 %. Laparoscopic or robotic Heller myotomy is an effective surgical treatment for achalasia. We present the first published case of a morbidly obese achalasia patient treated with robotic Heller myotomy and Dor fundoplication. The operative time was 175 min, with an estimated blood loss of 110 ml. The patient had a normal bowel transit on postoperative day 2, and he was discharged on postoperative day 4 on a liquid diet. A follow-up at 2 months showed significant resolved symptoms of achalasia.

Morbid obesity with achalasia: a surgical challenge

Achalasia is a relatively rare medical condition that is classically not associated with obesity. The surgical treatment of a simultaneous occurrence of these two diseases requires careful consideration, and only a few reports can be found in the literature combining a Heller myotomy with gastric bypass, duodenal switch, or gastric banding. We report the case of a 69-year-old female patient with early achalasia and obesity who underwent simultaneous laparoscopic gastric sleeve resection and robotic Heller myotomy. No intra- or postoperative complications occurred. A follow-up at 6 weeks showed a significant weight loss and resolved symptoms of achalasia. The case illustrates that a simultaneous gastric sleeve resection and robotic Heller myotomy might be an option for the treatment of concurrent obesity and achalasia.

Simultaneous surgical management of achalasia and morbid obesity

Achalasia presenting in the context of morbid obesity is rare. The case is presented of a woman with achalasia and morbid obesity who was treated with simultaneous laparoscopic esophageal myotomy and gastric bypass. The sparse literature addressing these rare patients is reviewed and management considerations discussed. Simultaneous laparoscopic esophageal myotomy and gastric bypass is safe, feasible and provides good results.

Achalasia after vertical banded gastroplasty for morbid obesity: A case report

Achalasia is an unusual motility disorder that can be seen in conjunction with obesity. The prevalence of achalasia is unknown in obese patients and when present, the clinical characteristics are atypical. We report a case of achalasia that was diagnosed 13 years after a vertical-banded gastroplasty was performed.