Case of The Week: Lap Band and Pseudo-achalasia

Adjustable gastric banding results in the formation of a thick fibrous capsule around the distal esophagus. In most cases the capsule is around 3 to 4 mm in thickness and spontaneously resolves after band removal. The patient I am presenting in this blog developed a thick fibrous capsule following lap Band placement measuring more than one cm in thickness. She is 30-year-old female with BMI=55 who presented to my office for evaluation of failure to lose weight 3 months after lap band placement at an outside institution. Her initial bariatric surgeon has attempted several times to adjust her band. Each adjustment had resulted in obstructive symptoms including nocturnal cough, food regurgitation, vomiting and inability to tolerate regular diet. The band was completely emptied and the patient was recommended lap band removal.

Prior to band removal, an esophagogram showed a dilated and tortuous esophagus with distal tertiary esophageal contractions. Contrast emptying from the esophagus into the stomach was delayed and incomplete. The lap band was in good position. There was evidence of narrowing of the distal esophagus at the level of the band. Esophageal manometry showed 90% failed contractions, weak contractile wave amplitude and decreased distal contractile integral. Residual lower esophageal sphincter pressure was slightly elevated at 17 mmHg while basal lower esophageal sphincter pressure was within normal. These findings are consistent with esophageal outflow obstruction. Weak contractions are either the result of prolonged esophageal outflow obstruction or intrinsic esophageal motility disorder. The patient may also evolve into achalasia with absent peristalsis and failure of the lower esophageal sphincter to relax. Currently, however, she does not meet the diagnostic criteria for achalasia.

The decision was made to remove the lap band and associated fibrous capsule as a possible cause of lower esophageal partial obstruction. Intraoperatively, a thick fibrous capsule, measuring more than one cm in thickness, was noted around the distal esophagus. The capsule was easily dissected off the esophageal wall and most of the anterior capsule was resected. Intraoperative endoscopy revealed a patent GEJ.

6 months after band removal, repeat esophagogram and manometry showed resolution of distal esophageal tertiary contractions, improvement in esophageal dilation, mild distal esophageal narrowing, and increased contractile wave amplitude and normal residual lower esophageal pressure. Patient subsequently underwent sleeve gastrectomy. Inspection of the GEJ revealed no residual fibrosis that might have prevented proper tissue stapling.

This case represents an unusual fibrotic reaction to Lap Band placement. The fibrous capsule that developed over a short period of time, has resulted in a pseudo-achalasia. Esophageal outflow obstruction led to nocturnal cough and food regurgitation that prevented band adjustment and possible weight loss. Performing a concomitant sleeve gastrectomy at the time of band removal might have been possible after capsulotomy. However, waiting 6 months and allowing the tissue to heal and recover prior to stapling is associated with a lower leak rate and better outcome.