Achalasia after laparoscopic sleeve gastrectomy treated with peroral endoscopic myotomy

Achalasia is a rare esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter (LES) and abnormal peristalsis in the esophageal body. Patients may have dysphagia, chest pain, and regurgitation, which present a clinical challenge, and many patients were misdiagnosed as gastroesophageal reflux disease. Herein, we wish to report a case of a 34-year-old woman diagnosed with type I achalasia 5 years after undergoing laparoscopic sleeve gastrectomy (LSG). The patient presented to our gastroenterology clinic with a 3-month history of progressive dysphagia to both solids and liquids, food regurgitation, chest pain, and postprandial vomiting, with an Eckardt score of 7. She had previously undergone LSG for morbid obesity 65 months prior to this visit. Her body weight decreased from 125.5 kg (body mass index [BMI] = 46.7) to 68.2 kg (BMI = 25.4) following the surgery. Notably, no obvious weight loss was found during the past 3 months despite dysphagia. Esophagogastroduodenoscopy revealed a dilated esophageal lumen with retained saliva, and a relatively tight and puckered LES (Figure 1A). Such findings remarkably differed from those observed 1 year before and 1 year after her bariatric surgery, including a non-dilated esophagus, relatively loose esophagogastric junction, and reflux esophagitis. Timed barium esophagram showed a dilated esophagus with delayed esophageal emptying. The barium column heights at 1, 2, and 5 min were 9.2, 4.1, and 3.1 cm, respectively, while the widths were 3.3, 3.1, and 3.1 cm, respectively (Figure 1B). High-resolution impedance manometry (HRIM) showed 100% failed contractions on wet swallows with a relatively high normal median LES-integrated relaxation pressure (IRP) of 18.5 mmHg (normal value