Post-Laparoscopic Sleeve Gastroplasty (LSG) Achalasia Cardia: A Rare Duo Managed by Peroral Endoscopic Myotomy (POEM)

Dysphagia following bariatric surgery is increasingly recognized, often due to post-obesity surgery esophageal dysfunction (POSED) or true achalasia cardia (AC). Peroral endoscopic myotomy (POEM) after laparoscopic sleeve gastroplasty (LSG) is rare, with only seven cases reported to date. We present the 8th case.

A 23-year-old male with morbid obesity (body mass index 38.2 kg/m²) underwent LSG in 2019, achieving approximately 20 kg weight loss. He later developed progressive dysphagia to solids and liquids over 1.5 years (Eckardt score: 8). Upper gastrointestinal endoscopy revealed a dilated esophagus with liquid residue and a tight lower esophageal sphincter (LES). High-resolution manometry confirmed type II AC with panesophageal pressurization (PEP) [Figure 1], and barium swallow showed complete contrast retention [Figure 2]. Computed Tomography shows a dilated and fluid filled oesophagus with remnant gastric sleeve following Laparoscopic sleeve gastrectomy. [Figure 3] The patient underwent successful POEM [Video 1]. Follow-up imaging at 24 hours showed smooth barium passage across the gastroesophageal junction [Figure 4]; manometry demonstrated loss of PEP and integrated relaxation pressure reduction to 4.3 [Figure 5].

Practical Implications for Endoscopists

• To differentiate POSED from AC in post-LSG dysphagia, manometry is essential; PEP suggests AC.[1]

• POEM is feasible and effective in post-LSG AC.[2]

• POEM in post-LSG AC more likely cause gastroesophageal reflux disease, need validation in further study.[1]

• Etiology of post-LSG AC is likely multifactorial: mechanical, neural, or hormonal.[2]

Fig. 1 Pre-peroral endoscopic myotomy (POEM) high-resolution esophageal manometry showing type II achalasia with elevated integrated relaxation pressure (IRP) and panesophageal pressurization.

Fig. 2 Time-barium esophagogram prior to peroral endoscopic myotomy (POEM) showing persistent contrast retention in the esophagus, indicative of achalasia cardia.

Fig. 3 Contrast-enhanced computed tomography (CT) image showing a dilated fluid-filled esophagus along with the remnant gastric sleeve following sleeve gastrectomy.

Fig. 4 (Learning image). Time-barium esophagogram following peroral endoscopic myotomy (POEM) demonstrating > 50% reduction in the height of the barium column compared with baseline, suggesting effective treatment response.

Fig. 5 Post-peroral endoscopic myotomy (POEM) high-resolution esophageal manometry demonstrating reduced integrated relaxation pressure (IRP) and resolution of panesophageal pressurization, confirming successful myotomy.

Video 1 Video shows treatment of achalasia cardia after laparoscopic sleeve gastrectomy with peroral endoscopic myotomy.

 

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Conflict of Interest

None declared.

• References

• 1 Miller AT, Matar R, Abu Dayyeh BK. et al. Postobesity surgery esophageal dysfunction: a combined cross-sectional prevalence study and retrospective analysis. Am J Gastroenterol 2020; 115 (10) 1669-1680
• 2 Maselli R, Fiacca M, Pellegatta G. et al. Peroral endoscopic myotomy for achalasia after bariatric surgery: a case report and review of the literature. Diagnostics (Basel) 2023; 13 (21) 3311

Publication History

Article published online:
28 July 2025