Background

Achalasia is a rare medical condition characterized by failure of relaxation of the lower esophageal sphincter due to esophageal motility disorder. Patient usually present with progressive dysphagia, regurgitation with retrosternal pain. Classically not associated with obesity. Treatment of achalasia and morbid obesity simultaneously need special careful consideration because few case reports found in the literature combining a management of two problems together.

Methods

We present the case of 30-year-old female with a BMI 41.7 status post endoscopic pneumatic dilatation of lower esophageal sphincter 10 years back. Post operative period passed with temporary improvement of dysphagia. Patient has maladaptive eating pattern with high sugar diet resulting into morbid obesity. Barium swallow revealed rat tail appearance. Upper GI Endoscopy revealed largely dilated esophagus with narrowing of lower esophageal sphincter. Esophageal manometry reveals failure of relaxation of lower esophageal sphincter confirm diagnosis of achalasia. Surgical plan is Heller myotomy with Roux-en-Y gastric bypass.

Results

Laparoscopic exploration started with identification of the hiatus and dissection of the esophagus up to the mediastinum. myotomy started at lower esophagus up to the 6 cm above, followed by myotomy 2cm below gastroesophageal sphincter. Furthermore, standard Roux-en-Y gastric bypass done. Lastly leak test was performed and was negative. Patient discharged on POD 2 with good condition and no complain.

Conclusions

Achalasia associated with morbid obesity is a rare condition. Combined Heller myotomy with Roux-en-Y gastric bypass is feasible, safe and effective for treatment of both diseases in the same operation.