A 35-year-old woman was admitted to the emergency department with progressive dysphagia for 6 years. Her symptoms worsened in the last 14 days followed by vomiting undigested and retained food eaten. The patient also complained about coughing since 6 years ago and was previously diagnosed with a variant respiratory problem but her symptoms didn't improve with medication. The patient had a heartburn and a history of weight loss. On physical examination she was found to have temperature 36.6  C, a heart rate of 113 bpm, a blood pressure of 117/83 mm Hg, and respiratory rate 21 bpm. She had an appearance of multiple depigmented patches with sharply defined borders and leucotrichia on the neck, abdomen, hand, knee, and lateral malleolus (Fig. 1). The patient had vitiligo for 18 years. The lesion altered in size from small dot, were itchy, progressive, not painful, and no blister. The patient had a sister with the appearance of vitiligo.
The patient underwent an upper gastrointestinal endoscopy and showed dilatation from distal oesophagus (38 cm from incisors) with retained food caused by narrowing gastro oesophagus junction (Fig. 2). The biopsy was not performed. Computed Tomography Scan Thorax revealed severe dilatation of oesophagus (diameter 4-7 cm) with narrowing in the distal level of gastrooesophagus sphincter, intraluminal fluid, shifting trachea to the right, shifting thyroid lobes to anterior and shifting left carotid artery to posterolateral left (Fig. 3).
After examining the symptoms and investigations, we conclude the diagnosis as achalasia. Considering the clinical history and physical exam findings, the diagnosis of vitiligo was given.
She was prescribed ranitidine and metoclopramide injection as a plan for initial management prior to surgery. Regarding the procedure, Laparoscopic Heller's myotomy was performed. The patient was placed in the French position (supine with the legs abducted on straight leg boards) with the operator stand between the legs and the surgical assistants stand one on each side of the patient. A 3-port procedure was taken, with a 10 mm port was used for camera port. The left liver lobe was retracted to the abdominal wall. We released oesophagus from crus anterior and posterior, and retracted with sling catheter modification. The myotomy of oesophagus musculature was performed with scissor and ultrasonic scissor (harmonic device) with the active blade in the upper side about 5 cm to proximal. The myotomy of the gastric side with monopolar cautery and splitting with grasper 2 cm distal to LOS. After the myotomy was made and leak testing was done with blowing the nasogastric tube, the opening of the esophagus was repaired with Dor's fundoplication (Fig. 4).
A post-operative study with a barium swallow of upper gastrointestinal radiograph was carried out 5 days following surgery, in which passage from oesophagus to jejunum without leakage, and no narrowing in oesophagus gastric junction at the distal oesophagus (Fig. 5A). Patient compliance was good throughout the treatment, and we also assess patient tolerance by monitoring blood routine and vital signs. The patient was discharged from the hospital on postoperative day 8 and is undergoing follow-up as an outpatient, with no dysphagia. Five months later the patient presented back with improvement were observed in upper gastrointestinal endoscopy, with a reduction in the sigmoid shape of oesophagus, good condition of LOS, and polyp 2 mm presented in the gastric corpus (Fig. 5B).