Achalasia-like syndrome presenting after highly selective vagotomy

Vagotomy is reported as a secondary cause of achalasia. Highly selective vagotomy, however, has rarely been reported to cause an achalasia-like syndrome. We suspect that periesophageal trauma accounted for the LES abnormalities seen at manometry in our patient but cannot explain the aperistalsis of the body of the esophagus. Pneumatic dilation improved his dysphagia only slightly but allowed him to maintain his nutrition with oral liquid enteral supplements. We recommend barium swallow, endoscopy, sounding the esophagus with a 50- to 60-French dilator, and manometry in evaluating patients with dysphagia after highly selective vagotomy. If an achalasia-like syndrome is demonstrated, then conservative management with observation and liquid nutritional supplements for four to eight weeks is appropriate. If this fails, pneumatic balloon dilation may be considered. Clearly, a preoperative history of dysphagia should prompt evaluation before highly selective vagotomy. This case represents a transient achalasia-like syndrome after highly selective vagotomy and signifies the importance of conservative management.