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

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.