Pseudoachalasia following insertion of a laparoscopic gastric band: a case report

Venkata Kollimarla, Akhila Rachakonda, Jennifer C. Myers, Steven Knox, Sarah K. Thompson

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Abstract

Background: Laparoscopic adjustable gastric banding (LAGB) is a common procedure to treat obesity. A potential complication of LAGB is pseudoachalasia (an esophageal motility disorder). In select individuals, a LAGB may create high outflow resistance, leading to a high-pressure environment in the distal esophagus, which then leads to progressive weakness and dilatation. Treatment of pseudoachalasia hinges on reversing the underlying cause. 

Case Description: A 64-year-old female, with morbid obesity [body mass index (BMI) 41 kg/m2] and a hiatus hernia, underwent laparoscopic insertion of a gastric band. As part of her procedure, a hiatal repair was performed with permanent braided sutures. Post-operatively, the patient lost 30 kg, however began to notice regurgitation and dysphagia. The laparoscopic band was removed a year later, but this did not alleviate her symptoms. Endoscopy showed an abnormal, dilated, fluid-filled esophagus. The patient underwent four endoscopic dilations over the next 24 months, with minimal benefit. On the fourth dilatation, the patient aspirated and developed aspiration pneumonia, resulting in a lengthy admission. Finally, the underlying cause was addressed with a laparoscopic takedown of the anterior hiatal repair and removal of the capsule (from the LAGB). Unfortunately, the patient's symptoms failed to improve over the next 12 months, and a difficult laparoscopic cardiomyotomy was performed. The patient subsequently improved and was then able to tolerate a normal diet. 

Conclusions: This case report highlights the critical nature of reversing all potential underlying causes when dealing with pseudoachalasia (i.e., removal of the LAGB and fibrotic capsule; takedown of a prior hiatal repair and/or fundoplication). As well, and of utmost importance, this case report reminds the reader that in a patient with severe symptoms of regurgitation and dysphagia, the airway must be protected during endoscopy to prevent aspiration.

Original languageEnglish
Article number46
Number of pages4
Journalannals of esophagus
Volume6
Early online date17 Jun 2022
DOIs
Publication statusPublished - 25 Dec 2023

Keywords

  • cardiomyotomy
  • high resolution manometry
  • Laparoscopic adjustable gastric banding (LAGB)
  • pseudoachalasia

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