A Novel Endoscopic Approach for Pseudoachalasia Secondary to Anti-Reflux Surgery

Abstract

Pseudoachalasia is an uncommon esophageal motility disorder that may clinically resemble idiopathic achalasia but is typically associated with secondary causes, such as malignancy or prior esophagogastric surgery. We report a 65-year-old female with a history of anti-reflux surgery who presented with progressive dysphagia and involuntary weight loss over a six-month period. Despite undergoing multiple sessions of pneumatic dilation, her symptoms remained unresolved. A comprehensive diagnostic workup, including barium esophagography, computed tomography, and endoscopic ultrasound, demonstrated a benign-appearing, long-segment fibrotic stricture in the distal esophagus, without evidence of malignancy. High-resolution manometry could not be performed due to poor patient tolerance. Given the failure of standard therapeutic modalities, we employed a novel endoscopic intervention Endoscopic Circular Stricturectomy (ECS) involving circumferential mucosal incision, excision of fibrotic tissue, and local steroid injection to minimize the risk of restenosis. The procedure was completed without complications, and esophageal patency was restored by postoperative day 5, allowing resumption of oral intake. Follow-up evaluations at one and two months confirmed sustained clinical improvement without recurrence. This case underscores the diagnostic complexity of pseudoachalasia, especially in the context of post-surgical fibrosis, and highlights the limitations of relying solely on manometric findings. ECS appears to be a feasible and minimally invasive therapeutic alternative to surgical revision in select cases of benign fibrotic esophageal strictures. Further investigation is warranted to establish its efficacy and safety in broader clinical settings.