I was asked if a patient with achalasia could have the duodenal switch operation.

My first reaction was why would anyone with achalasia need to have any weight loss surgery? This is because an almost universal finding with achalasia patients is significant weight loss.

The weight loss with achalasia is the result of dysphagia (inability to swallow) both solids and liquids. Patient with other esophageal motility disorders have primarily solid intolerance, but with proper positioning tolerate liquids well. This is because unlike other esophageal motility disorders (where the esophagus fails to push the food down after swallowing is initiated) in achalasia, the food is carried down to a certain level, but it gets stuck, because of non relaxation of muscles that form the lower esophageal. The key would be to make the proper diagnosis by manometry, endoscopy, and radiologic studies. The treatment for achalasia is very different-than that of an esophageal motility disorders.

Now going back to the question of a patient with achalasia having duodenal switch… If the diagnosis is correct, then the patient will benefit from a procedure where the outer muscle layers of the esophagus are divided, without entering the lumen of the esophagus. As a part of the same procedure,

the patient then has to have a Nissen wrap to prevent reflux. In my
opinion, any procedure that increase the possibility reflux should be avoided. Any procedure that causes vomiting should be avoided. Additionally from a technical perspective, for a Nissen wrap to be done, the top part of the stomach should be left intact.

In my opinion, this rules out the possibility of Adjustable gastric banding or the gastric bypass. Both of these are restrictive procedures that slow passage of the food past the stomach pouch. This is recreating the problem more than solving it.

Duodenal switch operation will probably be the best option. A larger stomach sleeve can be done, with a warp to prevent reflux. The lengths of the common and alimentary limbs can be adjusted so that the patient looses weight. I would have to once again raise the issue of correct diagnosis, in that most achalasia patients have significant weight loss, and will probably not be in the need of any weight loss surgery.

An esophageal motility disorder however is something that I have seen as a complication of Adjustable gastric banding. In a quest for more weight loss, the band is continuously filled. There is a fairly large body of scientific published data (both case reports and small series) that talk about the problem of AGB causing esophageal motility disorders.The universal belief is however, that the conversion to alternative operations, Duodenal switch or gastric bypass will is at least some cases reverse the motility disorder.