A 50-year-old morbidly obese man with a BMI of 51, hypertension, obstructive sleep apnea, and degenerative osteoarthritis had several episodes of aspiration pneumonia requiring hospitalization. He had been complaining for about one and a half year of progressive dysphagia, regurgitation, and coughing spells. An esophageal manometry showed type II achalasia according to the Chicago classification. He had been refusing surgery and had been treated with two pneumatic dilatations that resulted in mild and temporary resolution of dysphagia. Nevertheless, his dysphagia had worsened and now he is requesting surgical treatment for achalasia only. He is not interested in bariatric surgery.

In this case, our approach of choice consists in performing a laparoscopic Heller myotomy with a Dor fundoplication [4]. Figure 14.2 shows the completed operation.

The preoperative and postoperative management of patients with combined procedures is not any different from that of those who undergo only one procedure.

Achalasia and morbid obesity are two conditions that can be effectively treated surgically. However, the surgical treatment of achalasia may result in weight gain, which can be detrimental in patients with morbid obesity. On the other hand, the isolated treatment of morbid obesity does not treat the functional obstruction of the esophagus. Thus, surgical intervention should aim towards treating both diseases simultaneously and the approaches utilized should complement each other to achieve the desired outcome: relief of dysphagia and weight loss. Few reports in the literature have described three different techniques to achieve the goal of simultaneous treatment of achalasia and morbid obesity (Table 14.1).

The first approach consists in performing a laparoscopic Heller myotomy and a LRYGB [5, 6]. Kaufman et al. reported a case of a 25-year-old female who was diagnosed with achalasia and had a BMI of 58 kg/m². Achalasia was initially managed with pneumatic dilations, which resulted only in temporary relief of dysphagia. After a simultaneous laparoscopic Heller myotomy and LRYGB, the patient had excellent relief of dysphagia, no heartburn, and a weight loss of 100-lbs. one year postoperatively [5]. Similarly, O’Rourke et al. described a case of a 60-year-old female with a BMI of 52 kg/m² and a 10-year history of progressively worsening dysphagia. After several ineffective endoscopic pneumatic dilations and botulinum toxin injections, the patient underwent a simultaneous laparoscopic Heller myotomy and LRYGB. This treatment resulted in complete relief of dysphagia and a loss of 23 kg (33 % of excess body weight) at 6 months follow-up [6]. The LRYGB is also a safe option for those morbidly obese patients in whom achalasia was not detected prior to their initial bariatric operation. Oh et al. reported a patient with BMI of 49 kg/m² who initially underwent laparoscopic sleeve gastrectomy and was subsequently diagnosed with achalasia. This patient underwent a laparoscopic Heller myotomy along with conversion of a sleeve into a LRYGB that resulted in complete resolution of dysphagia and a decrease of her BMI to 31.5 kg/m² at a 6-months follow-up [7]. Similarly, Ramos et al. presented a case of a patient with a BMI of 47 kg/m² who started experiencing regurgitation and dysphagia 4 years after undergoing LRYGB. Esophageal manometry diagnosed achalasia and a laparoscopic Heller myotomy resulted in resolution of symptoms [8].