Alberto Aiolfi1, Diego Foschi2, Marco Antonio Zappa3, Alessandra Dell'Era2, Emilia Bareggi2, Emanuele Rausa4, Giancarlo Micheletto5, Davide Bona6. 1. Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy. alberto.aiolfi86@gmail.com. 2. Department of Biomedical and Clinical Sciences "Luigi Sacco", L. Sacco Hospital, Università degli Studi of Milan, 20157, Milan, Italy. 3. ASST Fatebenefratelli Sacco, UOC di Chirurgia Generale, Milan, Italy. 4. General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy. 5. Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy. 6. Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
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.
PURPOSE: Esophageal dysmotility and disorders of the lower esophageal sphincter are well documented in morbidly obesepatients. Esophageal achalasia has been reported in up to 1% of obesepatients 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.
Entities:
Keywords:
Dor fundoplication; Heller myotomy; Laparoscopic sleeve Gastrectomy; Video vignette
Authors: William O Richards; Alfonso Torquati; Michael D Holzman; Leena Khaitan; Daniel Byrne; Rami Lutfi; Kenneth W Sharp Journal: Ann Surg Date: 2004-09 Impact factor: 12.969