© FD-Communications Inc. Obesity Surgery, 15, 2005 713 Obesity Surgery, 15, 713-715 Weight loss is a frequent finding in achalasia because of the difficulty in swallowing. Although manometric findings compatible with achalasia have been found in morbidly obese patients, all of them were asympto- matic. The authors report a case of symptomatic achalasia and morbid obesity in a 38-year-old woman. A mental disorder become manifested after the patient was submitted to an esophageal myotomy and fundoplication. With weight gain, postoperative gas- troesophageal reflux developed. Drawbacks of further operative procedures in such a patient are discussed. Key words : Achalasia, morbid obesity, depression, mental disorder Introduction The main symptom of esophageal achalasia is dys- phagia. Weight loss is also a common complaint because of the difficulty in swallowing. Variable degrees of weight loss are found in more than 60% of these patients in different series. 1 Thus, the asso- ciation of achalasia and morbid obesity is rare. The authors report a case with this association in a patient with a mental disorder. Case Report A 38-year-old woman suffering from esophageal achalasia (whose etiology was attributed to Chagas’ disease) and obesity (Table 1) was referred to the digestive surgery service. Although the patient was symptomatic with a long period of dysphagia and was a candidate for surgical therapy for the achala- sia, she was intentionally treated nonoperatively for 8 years due to the fear of worsening her obesity. A mental disorder was at that time unsuspected. As the dysphagia worsened, the patient agreed to supervised weight loss, so that she could undergo surgery (Table 1). She underwent an esophageal myotomy and partial fundoplication (Heller-Pinotti procedure). 2 No surgical complications occurred, and postoperative routine examinations after 3 months (endoscopy, esophagogram) were normal. The patient quickly regained weight (Table 1) and developed gastroesophageal reflux symptoms. Then, a mental disorder, manifested by depression and alimen- tary compulsion, became evident. She regularly ingest- ed raw grains of rice and small pieces of food in order to “test” esophageal clearance. The patient was started on psychiatric treatment; however, a good response to treatment was not obtained. As gastroesophageal reflux symptoms became uncontrollable and dysphagia was again a complaint, she was re-operated and submitted to a cardioplasty, truncal vagotomy, antrectomy with a Case Report Obesity and Symptomatic Achalasia Fernando Augusto Mardiros Herbella, MD; Jacques Matone, MD; Laércio Gomes Lourenço, MD; Jose Carlos Del Grande, MD Esophagus and Stomach Division, Department of Surgery, Escola Paulista de Medicina, UNIFESP, São Paulo, SP, Brazil Reprint requests to: Dr. Fernando Herbella, Rua Diogo de Faria 1087, cj 301, São Paulo, SP 04037-003, Brazil. E-mail: herbella.dcir@unifesp.epm.br Table 1. Course of obesity Height Weight BMI (cm) (kg) (kg/m 2 ) At presentation (June 1995) 149 104 46.8 Preop 1st surgery (Feb 2003) 149 82.6 37.2 Preop 2nd surgery (Nov 2003) 149 96.0 43.2 Current (Dec 2004) 149 80.0 36.0