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

Introduction

In Australia, over 31% of the adult population are obese (1). When patients are morbidly obese and/or have medical complications due to their obesity, bariatric surgery is recommended. Laparoscopic adjustable gastric banding (LAGB) involves surgical constriction of the stomach fundus with a silicone band, resulting in early satiety and consequent weight loss. A potential complication of LAGB is pseudoachalasia.

Pseudoachalasia, or secondary achalasia, is an esophageal motility disorder. Although symptoms (dysphagia and regurgitation), barium studies, and manometry findings are indistinguishable to that of primary achalasia, pathophysiology differs. Achalasia is caused by idiopathic degeneration of the myenteric plexus leading to unopposed tonicity of the lower esophageal sphincter (LES). However, pseudoachalasia may occur as a secondary complication of a malignancy at the gastroesophageal junction (GEJ) or any type of surgical procedure at the hiatus, including LAGB (2,3). This may create high outflow resistance, leading to a high-pressure environment in the distal esophagus, and may result in progressive weakening and dilatation of esophagus (4).

Management of pseudoachalasia hinges on reversing the underlying cause (2,5). We present a case of pseudoachalasia following LAGB insertion and hiatus hernia repair and discuss the important learning outcomes of this difficult problem. We present this case in accordance with the CARE reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-22-5/rc).

Case presentation

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. Prior to her procedure, she had no symptoms of dysphagia nor regurgitation, and was enjoying a normal diet. As part of her operation, an uncalibrated anterior hiatal repair was performed with permanent braided sutures. Post-operatively, the patient lost 30 kg, however began to notice regurgitation. As a result, the laparoscopic band was removed a year later, but this did not alleviate her symptoms. Endoscopy showed an abnormal, dilated, fluid-filled esophagus, with a moderately tight LES. Manometry and barium swallow showed findings similar to, yet an imperfect mimic of achalasia (Figures 1,2). Manometry depicted absence of peristalsis, pan-esophageal pressurization, and incomplete GEJ relaxation on swallowing with an abnormal integrated relaxation pressure, IRP-4s, consistent with an achalasia-like syndrome (Figure 1). A self-reported dysphagia composite score was 37.5 out of 45, where 0 is none and 45 is severe (6).

Figure 1 Initial barium swallow following removal of laparoscopic band, but without removal of fibrotic capsule or takedown of hiatal repair.

Figure 2 Esophageal high-resolution manometry with pan-esophageal pressurization and incomplete gastroesophageal junction relaxation, consistent with post-surgical pseudoachalasia (10 wet swallows, mean integrated relaxation pressure =23 mmHg, normal <15 mmHg).

The patient underwent three endoscopic dilations with a 30–35 mm Rigiflex^TM balloon (Boston Scientific Corporation, Marlborough MA, USA) over the next 24 months. Minimal benefit was observed and symptoms worsened with daily regurgitation leading the patient to a fluid only diet. The treating surgeon decided upon a fourth endoscopic dilatation but, on induction, the patient aspirated and developed aspiration pneumonia. This resulted in a 9-day intensive care unit stay and a 28-day hospital admission. At this point, our team was consulted.

The decision was made to treat the underlying cause, and a laparoscopic takedown of the anterior hiatal repair and removal of the capsule (from the LAGB) were performed. Unfortunately, the patient’s symptoms failed to improve over the next 12 months, with ongoing regurgitation and inability to tolerate solids. Therefore, a difficult laparoscopic cardiomyotomy was completed with endoscopic guidance due to substantial fibrosis and scar tissue. The patient subsequently improved and was then able to tolerate a normal diet. Her most recent barium swallow demonstrating a dilated esophagus, although with improved GEJ calibre, is shown (Figure 3), and her dysphagia composite score is now 16.5 out of 45 (6).

Figure 3 Barium swallow following removal of fibrotic capsule, takedown of hiatal repair, and laparoscopic cardiomyotomy (image taken 12 months post-operatively).

All procedures performed in this study were in accordance with the ethical standards of the institutional committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

When pseudoachalasia occurs secondary to a laparoscopic band, complete resolution of symptoms after release of the LAGB has been noted in literature (4). Our case report however highlights the importance of removing the fibrotic capsule as well as releasing any prior hiatal repair. This patient was initially treated as an idiopathic achalasia patient with repeated balloon dilatations. The appropriate first step in our patient, recognizing that this was pseudoachalasia and not primary achalasia, would have been reversal of all interventions at the hiatus. There are some important lessons in this case, highlighted by the patient’s imaging studies.

First, pseudoachalasia is a potential complication of any procedure at the hiatus if there is esophageal outflow obstruction into the stomach (e.g., LAGB, laparoscopic anti-reflux surgery). That said, the most common cause of this rare condition is a tumour at the GEJ, usually adenocarcinoma (2). Second, when pseudoachalasia is suspected, manometry should be the diagnostic modality of choice due to its high sensitivity (88%) compared to barium swallow (77%) and endoscopy (12%) (3). Third, management of pseudoachalasia hinges upon the reversal of the underlying cause (i.e., removal of the LAGB and fibrotic capsule; takedown of a prior hiatal repair and/or fundoplication). Results from a study by Pescarus et al. demonstrate that endoscopic division of LAGB-induced fibrosis leads to restoration of esophageal peristalsis in 30% of cases (7). If this intervention fails, a cardiomyotomy is then indicated. Last, and of utmost importance, in a patient with severe symptoms of regurgitation and dysphagia, the airway must be protected during endoscopy, preferably with an endotracheal tube.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-22-5/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-22-5/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-22-5/coif). S.K.T. serves as an unpaid editorial board member of Annals of Esophagus from September 2019 to August 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional committee and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Australian Institute of Health and Welfare. Overweight and obesity. Australian Institute of Health and Welfare. Canberra: Australian Government, 2021. [online] [Release date 23 July, 2020; cited 24 May, 2021]. Available online: https://www.aihw.gov.au/reports/australias-health/overweight-and-obesity
2. Barnett DR, Balalis GL, Myers JC, Devitt PG. Diagnosis and treatment of pseudoachalasia: how to catch the mimic. Ann Esophagus 2020;3:16. [Crossref]
3. Schizas D, Theochari NA, Katsaros I, et al. Pseudoachalasia: a systematic review of the literature. Esophagus 2020;17:216-22. [Crossref] [PubMed]
4. Lipka S, Katz S. Reversible pseudoachalasia in a patient with laparoscopic adjustable gastric banding. Gastroenterol Hepatol (N Y) 2013;9:469-71. [PubMed]
5. Roushan N, Zolfaghari A, Asadi M, et al. Pseudoachalasia: a diagnostic challenge. Med J Islam Repub Iran 2014;28:54. [PubMed]
6. Dakkak M, Bennett JR. A new dysphagia score with objective validation. J Clin Gastroenterol 1992;14:99-100. [Crossref] [PubMed]
7. Pescarus R, Sharata A, Shlomovitz E, et al. Endoscopic treatment for iatrogenic achalasia post-laparoscopic adjustable gastric banding. Surg Endosc 2016;30:3099. [Crossref] [PubMed]