title: Achalasia: A case report on its effect during surgical decision making for laparoscopic sleeve gastrectomy in the young morbidly obese patient.
abstract: BACKGROUND
  Achalasia is a condition that occurs when the lower esophageal sphincter (LES) fails to properly relax, combined with slowing/failure of esophageal peristalsis. This is seen clinically by not allowing solids and liquids to pass easily into the stomach. Achalasia is not historically associated with morbid obesity, yet dual treatment of morbid obesity and achalasia is becoming more prominent due to the worldwide obesity epidemic.
  
  
  METHODS
  Achalasia is typically a disease that affects non-obese adults over the age of 55, which makes the discussion of this case report unique in that our patient is a 23 year-old woman who successfully underwent per-oral endoscopic myotomy (POEM) in preparation for a future laparoscopic sleeve gastrectomy. There is sparse literature on combining laparoscopic Heller myotomy (LHM) and partial fundoplication versus POEM with either restrictive or malabsorptive minimally invasive bariatric procedures.
  
  
  CONCLUSIONS
  LHM and partial fundoplication have long been considered the gold standard surgical treatment for achalasia by disrupting both the longitudinal and circular muscle layers of the LES. The newer, less invasive, POEM technique will be compared to the gold standard LHM and Dor fundoplication in this uncharacteristically young morbidly obese achalasia patient. The decision to pursue a laparoscopic sleeve gastrectomy over a laparoscopic Roux-en-Y gastric bypass was multifactorial due to the patient's concerns regarding malabsorption of vitamins and nutrients in the event of a future pregnancy.
  
  
  CONCLUSIONS
  The patient has already undergone a POEM procedure, which was chosen to maintain the gastric fundus, cardia, and gastroesophageal junction (GEJ) architecture as opposed to a LHM with Dor fundoplication, which would have altered the anatomy, thus making a concomitant laparoscopic sleeve gastrectomy an unfeasible option.
authors.affiliation: Capital Regional Surgical Associates, 2626 Care Drive, Suite 206, Tallahassee, FL, 32308, USA; Florida State University College of Medicine, Clinical Assistant Professor of Surgery, 1115 W Call St, Tallahassee, FL 32304, USA. Electronic address: rodolfo.j.oviedo@gmail.com.
authors.forename: Rodolfo J
authors.initials: RJ
authors.lastname: Oviedo
authors.affiliation: Alabama College of Osteopathic Medicine, Class of 2017, 445 Health Sciences Blvd, Dothan, AL 36303, USA. Electronic address: sofiakcw@acomedu.org.
authors.forename: Chase W
authors.initials: CW
authors.lastname: Sofiak
authors.affiliation: Alabama College of Osteopathic Medicine, Class of 2017, 445 Health Sciences Blvd, Dothan, AL 36303, USA. Electronic address: dixonbm@acomedu.org.
authors.forename: Bruce M
authors.initials: BM
authors.lastname: Dixon
keywords: Achalasia; Bariatric surgery; Heller myotomy; Laparoscopic sleeve gastrectomy; Morbid obesity; POEM (per-oral endoscopic myotomy)