Achalasia is a rare esophageal dysmotility disorder of unknown etiology. It is characterized by loss of esophageal peristalsis and failure of the lower esophageal sphincter to relax. Patients develop dysphagia to solids and liquids.

Traditionally, achalasia patients lose weight due to inability to eat regular food. Most end stage achalasia patients present in a malnourished and underweight state. These days, however, almost all achalasia patients referred to Houston Weight Loss Surgery Center are overweight or obese. Obese achalasia patients report gaining weight concomitantly with their dysphagia progression. Patients with difficulty swallowing, replace their regular diet with calorie dense liquids or soft food items. Fruits, vegetables, meats and complex carbohydrates gradually become harder and harder to swallow. Thus, achalasia patients limit their diet to sweets, ice cream and milkshakes… Such a high glycemic index diet is likely to contribute to gradual weight gain as achalasia progresses over time. Consequently, overweight patients who develop achalasia tend to be obese upon presentation for evaluation.

Heller myotomy with partial fundoplication is the traditional treatment for achalasia. For obese patients, however, adding a Roux-en-Y gastric bypass instead of fundoplication seems to be more advantageous for several reasons. Obese achalasia patients constitute 45% of our achalasia patients at Houston Weight Loss Surgery Center. The remaining patients are overweight. A weight loss procedure in the setting of a Heller myotomy offers the obese achalasia patient an opportunity to fix 3 problems at the same time: Obesity, GERD and Dysphagia. I prefer Roux-en-Y gastric bypass over gastric sleeve surgery following Heller myotomy for three reasons. First, gastric bypass surgery preserves the stomach as a potential conduit for future esophageal reconstruction in case esophagectomy is needed in the future. Achalasia patients are at higher risk for developing esophageal cancer and esophageal resection may be needed. Second, Roux-en-Y configuration of gastric bypass surgery is a negative pressure system that promotes esophageal food emptying. Gastric sleeve lumen pressure is typically elevated (at least per published studies) and may theoretically hamper esophageal emptying. Third, I have had great experience alleviating GERD related symptoms in Lap Band patients who developed pseudo-achalasia due to long-term band over-restriction. I have performed around 25 band to gastric bypass conversions in these situations with excellent results. Food regurgitation, heartburn and aspirations successfully resolved following gastric bypass surgery even in the setting of a massively dilated esophagus.