Development of pseudoachalasia following magnetic sphincter augmentation (MSA) with restoration of peristalsis after end
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CASE REPORT
Development of pseudoachalasia following magnetic sphincter augmentation (MSA) with restoration of peristalsis after endoscopic dilation Katrin Schwameis1 · Shahin Ayazi1 · Ali H. Zaidi1 · Toshitaka Hoppo1 · Blair A. Jobe1 Received: 14 April 2020 / Accepted: 18 May 2020 © Japanese Society of Gastroenterology 2020
Abstract Pseudoachalasia is mimicking clinical and physiologic manifestations of idiopathic achalasia but results from alternative etiologies that infiltrate or obstruct the esophagogastric junction (EGJ). Anti-reflux surgery is one of the potential etiologies of pseudoachalasia. The majority of cases with persistent dysphagia after a tightly constructed Nissen fundoplication results from EGJ outlet obstruction (EGJOO) and in rare cases progresses to pseudoachalasia. In these extreme cases, endoscopic dilation is not a sufficient treatment and take down of fundoplication would be necessary. In this case report, we present a patient with long-standing GERD symptoms that underwent magnetic sphincter augmentation (MSA) with complete resolution of his reflux symptoms. He did not have dysphagia prior to surgery and his preoperative manometry showed normal peristaltic progression of esophageal contractions. He developed pseudoachalasia 14 months after surgery. Repeated endoscopic dilation in this case resulted in resolution of dysphagia and complete restoration of peristaltic contractions. Keywords Gastroesophageal reflux disease (GERD) · Magnetic sphincter augmentation (MSA) · Nissen fundoplication · Pseudoachalasia · Esophagogastric outflow obstruction (EGJOO) · Dysphagia A rare complication after anti-reflux surgery is the development of pseudoachalasia, an uncommon esophageal motor disorder that mirrors clinical and manometric features of idiopathic achalasia. These two entities result from distinct etiologies, but they are both characterized by incomplete relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body [1]. The development of primary achalasia is based on the loss of inhibitory neurons in the myenteric plexus of the esophagus likely from an immune response to an unknown antigen [2]. In contrast, a broad spectrum of disorders and procedures can lead to the development of pseudoachalasia. Seventy percent of cases are malignancy associated and despite varying pathophysiology, the common underlying mechanism is mechanical or functional alteration at the esophagogastric junction (EGJ) or the myenteric plexus of the distal esophagus [3].
* Shahin Ayazi [email protected] 1
Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA 15224, USA
Anti-reflux procedures are designed to mechanically restore the defective anti-reflux barrier. This can increase esophageal outflow resistance that can lead to esophagogastric outflow obstruction (EGJOO). In rare cases, this can result in the impairment of esophageal peristalsis with the extreme variant being secondary achalasia [4]. In the current manuscript, we p
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