Pseudoachalasia after radical gastrectomy

Abstract

Case reportsanastomosis with a Roux-en-Y loop was fashioned. Histological examination of the resected specimen showed a moderately differentiated adenocarcinoma. The resected margins were free of tumour but lymph nodes from the greater curve and lesser curve contained metastatic tumour.The patient remained well until 6 months later when he was readmitted to hospital with postprandial vomiting. There was no dysphagia and appetite was preserved, although weight loss of 5 kg over the preceding month was documented.A barium meal demonstrated a functional obstruction of the lower oesophagus with a smoothly tapered narrow segment, which opened only when an adequate column of barium produced sufficient pressure ( Figure I); the appearances resembled achalasia. There was no evidence of stricture at the anastomosis or of tumour recurrence and barium passed freely into the jejunal loop.At endoscopy the lower oesophagus was thought to be slightly rigid but otherwise normal. The jejunum was entered easily and appeared normal. Biopsies from the anastomosis and adjacent mucosa showed no evidence of malignancy or inflammation.Balloon dilatation of the distal oesophagus was performed and the lower oesophagus dilated readily. A repeat barium swallow 6 days later showed some improvement with less lower oesophageal spasm, although the appearances still resembled achalasia.A small bowel meal via a tube introduced into the efferent loop suggested extrinsic compression I5 cm from the anastomosis site. At laparotomy there was extensive peritoneal disease with encasement of the lower end of the oesophagus by plaque-like tumour. There was no possibility of palliative surgery. The patient died postoperatively and post-mortem examination was not performed. We report the case of a patient who had a radical total gastrectomy with oesophagojejunostomy for an adenocdrcinoma of the stomach. This patient subsequently demonstrated radiological and endoscopic features of achalasia, although these were not present at the time of presentation of the carcinoma. Case historyA 69-year-old man presented with breathlessness and anaemia. A double-contrast barium meal revealed a tumour high on the lesser curve of the stomach, which was confirmed by endoscopic biopsy to be an adenocarcinoma.A radical total gastrectomy, splenectomy and distal pancreatectomy with omentectomy was performed. A stapled oesophagojejunal DiscussionPrimary achalasia is a motility disorder of the oesophagus of unknown cause.On barium studies achalasia has characteristic features. There is failure of relaxation of the lower oesophageal sphincter with the lower end showing smooth symmetrical narrowing. In the horizontal position barium does not pass into the stomach, but in the upright position the barium column is retained above the lower oesophageal sphincter until its hydrostatic pressure overcomes the resistance and barium squirts into the stomach. 97

Pseudoachalasia in a patient after truncal vagotomy surgery successfully treated by subsequent pneumatic dilations

“…Some are from benign diseases, such as pancreatic pseudocysts, mesenchymal tumors of the esophagus and mediastinal fibrosis [11][12][13][14][15] . In rare instances, pseudoachalasia may be a complication of various surgeries, the majority being antireflux procedures, gastric banding and gastrectomy [9,16,17] .…”

“…Our case resulted as a complication from truncal vagotomy for pyloric obstrction. The mechanisms of esophageal motor dysfunction in pseudoachalasia have been proposed as follows [17] :…”