Background

This abstract presents a novel proposal for managing achalasia in patients with morbid obesity.Our patient is a 54-year-old female patient with a history of morbid obesity, metabolic syndrome including hypertension, hyperlipidemia, uncontrolled type 2 diabetes mellitus on insulin, and severe gastroesophageal reflux disease (GERD).The patient presented with a nine-month history of progressive dysphagia, nausea, and vomiting. Additionally, she experienced a significant 60-pound weight loss over the past four months, with a current BMI of 45 kg/m2. Extensive workup, including esophagogastroduodenoscopy (EGD) and esophageal manometry with esophagogram, revealed a positive diagnosis of achalasia.Achalasia management with myotomy with endoscopic and surgical approaches is well described in the literature. However, in the presence of morbid obesity, the definitive treatment of both diseases is treated by Roux-en-Y gastric bypass (RYGB) and concurrent Heller myotomy (HM).Given the technical complexities of performing laparoscopic HM and Roux-en-Y gastric bypass (RYGB) due to the small gastric pouch, we present an innovative approach in our video. In our presentation, an esophagojejunostomy with stapling through the lower esophageal sphincter is an alternative technique to a traditional myotomy. This technique addresses the challenges related to the limited space within the gastric pouch while ensuring an adequate myotomy length. During the video, we discuss the advantages, technical considerations, and implications of this proposed approach, offering a promising avenue for the surgical management of achalasia with morbid obesity.