Obesity and achalasia: challenges in diagnosing and treating them

Achalasia and obesity are rarely found concomitantly, making it hard to properly diagnose. Considering esophageal dysmotility and dietary disorders, weight gain is rare in patients with achalasia. Complaints such as dyspepsia and dysphagia resulting from esophageal disorder can be erroneously overlooked whereas these complaints are also common in patients with obesity. Surgical approach must address the solution of all the dysfunction simultaneously since disconnected interventions can cancel the benefit of each other. We report a case of a patient with obesity, difficult achalasia diagnosis and excellent clinical outcome with synchronic surgical approach of Roux-en-Y gastric bypass (RYGB) and Heller myotomy. A 33-year-old female patient, 41.2 BMI, presents dysphagia and dyspepsia with previous gastroesophageal reflux disease diagnosis. Considering her 5 points in Eckardt scale, the esophageal manometry result and the radiography imaging of esophagus and stomach with contrast the patient was diagnosed with achalasia. Given the previous literature, we chose to perform a Roux-en-Y gastric bypass and a esophageal Heller myotomy in a single laparoscopic surgery. The patient successfully lowered her BMI and does not present any other symptoms. We suggest that patients with achalasia and obesity may be managed with a single surgical intervention including Heller myotomy and RYGB. Symptoms suggesting achalasia must be evaluated even in patients with obesity. The diagnosis can require esophageal manometry and radiography with oral contrast. The diagnosis and surgical treatment of concomitant achalasia and obesity is complex and must be preceded by a qualified medical team.