Laparoscopic Heller Myotomy and Dor Fundoplication for the Treatment of Esophageal Achalasia After Sleeve Gastrectomy—a Video Vignette

Abstract

Purpose Esophageal dysmotility and disorders of the lower esophageal sphincter are well documented in morbidly obese patients. Esophageal achalasia has been reported in up to 1% of obese patients but the development of such esophageal motility disorder after laparoscopic sleeve gastrectomy (LSG) is extremely rare. The purpose of this video was to demonstrate the management of a type II esophageal achalasia diagnosed in a 46-year-old female patient 4-year after LSG. Materials and Methods An intraoperative video has been anonymized and edited to demonstrate the feasibility of laparoscopic Heller myotomy and anterior Dor fundoplication on the mentioned patient. Results The operation started with the section of the perigastric adhesions. Proceeding in a clockwise direction, the esophagogastric junction, the anterior esophageal wall, and the His angle were freed. A residual slightly dilated fundus was found and isolated. After mobilization of the distal esophagus and identification of the anterior vagus nerve, a “hockey stick” myotomy was carried out for 6 cm on the esophagus and for 2 cm on the gastric side. An anterior Dor fundoplication was fashioned using the residual gastric fundus. Conclusion Esophageal achalasia in patients that previously underwent LSG is exceptional but should always be suspected in case of pathognomonic symptoms onset. In tertiary referral centers, laparoscopic Heller myotomy and, if technically feasible, an anterior Dor fundoplication seem safe and effective to relieve gastroesophageal outflow obstruction and prevent gastroesophageal reflux.

Laparoscopic Heller myotomy with Dor fundoplication for esophageal achalasia treatment after distal gastrectomy and Billroth‐II reconstruction

“…We performed a literature search using MEDLINE (2005–2023) with search terms including “achalasia,” “distal gastrectomy,” and “laparoscopic Heller myotomy,” but we identified no reports similar to our case, although some reports after bariatric surgery were identified 4,5,9,10 . However, we are aware that similar cases must exist, and we therefore believe it is important to share the findings.…”

“…The most effective treatment for this condition is surgical intervention. Reviewing the reports of esophageal achalasia after gastric surgery, 4,5 POEM seems to be the recent mainstay approach 6,7 . POEM is a minimally invasive and effective treatment for esophageal achalasia, and it is the endoscopic counterpart of laparoscopic Heller myotomy.…”