Pseudo-achalasia following laparoscopically placed adjustable gastric banding

Background: The complication of pseudo-achalasia may occur after laparoscop ic adjustable gastric banding (LAGB) in patients with normal band position and normal stomal width. We hypothesized that this complication occurs espe cially in patients with preexisting insufficiency of the lower esophageal s phincter (LES), who show poor compliance secondary to lacking the sensation of satiety and who therefore also have insufficient weight loss at followu p. Methods: Early and late postoperative barium meal studies of 120 LAGB patie nts were retrospectively analyzed to identify patients who developed esopha geal widening and dysmotility despite normal band position and normal stoma l width. Results were compared with preoperative endoscopies, clinical find ings, each patient's compliance with dietary instructions and postoperative weight loss. Results: 9/120 patients developed pouch dilatation, esophageal widening and esophageal dysmotility as a late complication, despite normal band positio n and normal stomal width. All these patients had shown preexisting insuffi ciency of their LES endoscopically, They all showed bad compliance with die tary instruction, and they all abused their distal esophagus as an addition al pouch. 7 of these patients presented with insufficient weight loss at fo llow-up, whereas of 3 other patients with pre-existing LES insufficiency wh o had shown good compliance, only 1 showed insufficient weight loss. Insuff icient weight loss after 1 year was significantly more common in patients w ith pre-existing LES insufficiency (8/12 patients, 67%) than in patients wi th a competent LES (26/108 patients, 24%). Conclusion: Patients with pre-existing LES insufficiency appear to be at ri sk for pouch dilatation and esophageal decompensation despite normal band p osition and normal stomal width,These patients are prone to show lack of sa tiety and poor compliance with dietary instruction, use of their lower esop hagus as additional space for food, and tend to have insufficient weight lo ss. Preoperative manometry should be used to identify such patients, where the indication for gastric banding should be discussed very critically.