Case Report: a Single-Patient Experience with Trans-Sphincteric Esophagojejunostomy for Concurrent Achalasia and Morbid Obesity.

disclaimerThis case report describes an investigational, non-standard technique performed in a high-expertise center. It should not be considered standard of care and should not be attempted outside carefully selected indications, multidisciplinary oversight, and appropriate institutional governance (e.g., IRB/innovation review).

backgroundThe coexistence of achalasia in a patient with morbid obesity presents a unique, rare, and complex clinical challenge. One might consider a staged approach, addressing the achalasia first and morbid obesity at a later date. Alternatively, a myotomy (POEM or Heller) may be performed along with a bariatric procedure. However, the technical expertise required would be beyond the abilities of most surgeons.

objectivesTo describe, for educational and hypothesis-generating purposes, a novel, single-stage surgical technique that addresses both morbid obesity and achalasia using a stapled trans-sphincteric esophagojejunostomy, achieving full-thickness myotomy while preserving the stomach and avoiding the technical limitations of standard dual approaches.

settingAcademic tertiary care center, United States.

methodsWe present a case of a 54-year-old woman with a BMI of 45 kg/m², severe GERD, and type II achalasia confirmed by EGD, manometry, and esophagogram. The procedure involved a stapled esophagojejunostomy through the lower esophageal sphincter, achieving a full-thickness myotomy combined with a Roux-en-Y Gastric Bypass anatomy.

resultsThe patient demonstrated resolution of dysphagia and reflux symptoms, tolerance of oral intake, and 76% excess weight loss at two years without perioperative complications and with excellent nutrition and vitamin levels. These findings are limited to a single case and carry specific risks and can only be considered cautiously, while this technique allows definitive treatment of both disorders while avoiding the technical challenges of the traditional approaches and potentially minimizing recurrence, its broader safety and efficacy remain unproven.

conclusionsThis report illustrates a technically feasible but investigational approach for a highly selected patient with concurrent achalasia and morbid obesity. It simplifies the anatomy, preserving gastric tissue and enabling a complete myotomy; however, it is based on a single case, and broader application would require formal evaluation under controlled investigational protocols.