Circular Myotomy Research Articles

A Case of Esophageal Leiomyoma Resected After Selective Circular Myotomy in Submucosal Tunneling Endoscopic Resection

A Case of Esophageal Leiomyoma Resected After Selective Circular Myotomy in Submucosal Tunneling Endoscopic Resection

S1864 Cricopharyngeal Per Oral Myotomy (C-POEM) for Treatment of a Cricopharyngeal Bar: A Novel Technique

INTRODUCTION: Primary cricopharyngeal achalasia is a rare functional pathology and sub-type of traditional achalasia. While the exact etiology is unknown, it is characterized by a lack of pharyngeal contraction, improper coordination between the pharynx and upper esophageal sphincter (UES) or the inability of the UES to relax. The majority of the UES is made up of the cricopharyngeal muscle. Traditional treatment modalities include pneumatic dilatation, Botox injection and surgical myotomy. Cricopharyngeal per oral myotomy (C-POEM) can be an effective alternative minimally invasive procedure for patients before opting for more invasive surgical procedures. CASE DESCRIPTION/METHODS: A 76-year-old female presented with dysphagia for both liquid and solids. She was found to have cricopharyngeal achalasia on esophageal manometry. Past medical/surgical history included hypertension, hysterectomy and cholecystectomy. Pre-procedure esophagram visualized a non-relaxing cricopharyngeus muscle and was recommended to undergo C-POEM. A submucosal injection of ORISE lifting gel was used to elevate the mucosa to provide cushion for entry at the site of the initial dissection. The initial mucosal incision was made transversely using a Hybrid Knife I-Type. Then submucosal tunneling began through dissection of submucosal fibrous and connective tissues. The submucosal dissection was used to identify the cricopharyngeal bar. Once, submucosal tunneling was complete. circular myotomy of the cricopharyngeal muscle was performed along the longitudinal axis of the submucosal tunneling. Bleeding was minimal throughout the procedure and cautery was used effectively for hemostasis. The defect was closed using 3 endoscopic clips. Follow up endoscopy did show a healed scar from the tunnel entry. The upper esophageal sphincter was inspected with no cricopharyngeal bar re-occurrence. The patient's cricopharyngeal bar dysphagia was completely resolved. DISCUSSION: We have demonstrated the safety and efficacy of the POEM procedure in patients with cricopharyngeal bar. Along with more traditional therapeutic options, the C-POEM should be considered a viable alternative in patients suffering from cricopharyngeal bar.Figure 1.: Pre-POEM esophagram displaying a non-relaxing cricopharyngeus muscle.Figure 2.: Continued submucosal dissection to the cricopharyngeus muscle layer.Figure 3.: Myotomy of the cricopharyngeal muscle layer.

Risk factors for gastroesophageal reflux after POEM for achalasia: a systematic review and meta-analysis.

Peroral endoscopic myotomy (POEM) demonstrated similar efficacy to surgical myotomy in the management of achalasia. However, gastroesophageal reflux disease (GERD) is common after POEM. The aim of this study is to identify factors associated with GERD after POEM. After searching electronic databases, randomized trials and observational studies including patients with achalasia or other spastic esophageal disorders, treated by POEM, and providing GERD data were selected. GERD was evaluated by 3 methods: pH monitoring, endoscopic findings, and symptoms. For each method, an analysis was performed comparing the outcomes related to the following independent variables: full-thickness (FT) vs circular myotomy, anterior vs posterior, long myotomy vs short myotomy, naive vs previous treatment failure, previous Heller myotomy (HM) vs non-previous-HM, Type I vs II, Type I vs III, and Type II vs III. 2869 publications were identified, and 25 studies met criteria for inclusion in the qualitative analysis. Of these, 18 were included in the meta-analysis. According to the endoscopic findings, circular and anterior myotomy demonstrated a lower trend of GERD with borderline significance (p = 0.06; p = 0.07, respectively). In the pH monitoring and symptom analyses, circular myotomy, anterior myotomy, treatment naive, and non-HM patients were associated with a lower occurrence of GERD; however, no statistically significant difference was found. When comparing achalasia subtypes, no statistical difference was found in all analyses. This systematic review and meta-analysis suggest that a circular anterior approach may limit post-POEM GERD and should be considered in appropriate patients.

Primary repair of long gap esophageal atresia in a neonate employing circular myotomy on upper pouch and a novel hemicircular myotomy on the distal pouch

Abstract Introduction Pure esophageal atresia (EA) with long gap between the pouches remains a challenge for primary repair. Several techniques to facilitate primary repair in long gap EA have been described: complete mobilization of proximal and/or distal esophageal pouch, single or double circular myotomies or spiral myotomy of upper pouch, circular myotomy of both upper and lower pouch, flaps raised from the upper pouch to bridge the gap and external traction sutures. Some of these techniques are not routinely performed for anatomical reasons or unfamiliarity with the technique. Complete mobilization of upper pouch with circular myotomy is standard and often favored approach. Complete mobilization of lower pouch with or without circular myotomy is described. It has a risk of impairing the blood supply to the lower pouch due to segmental nature of its blood supply. We present a novel case of primary repair of this defect using a circular myotomy on upper pouch along with a hemicircular myotomy of the lower pouch without complete circumferential mobilization of the lower esophageal pouch. This allowed adequate lengthening of the lower pouch without compromising its blood supply facilitating a minimal tension primary repair. Case We report the case of a 38 4/7 term infant with intra-uterine growth retardation (IUGR) and Tetralogy of Fallot (TOF) with a long 4.5 cm gap pure esophageal atresia who was repaired aged 16 weeks. Per-operative gap assessment revealed the gap to more than 4 vertebral bodies. Even after complete mobilization of the upper esophageal pouch, a 2.5 cm (cm) gap persisted. The upper pouch was narrow and hence unsuitable to facilitate flap reconstruction. A single circular myotomy was performed on the upper esophageal pouch approximately 1 cm proximal to its blind end. The lower pouch was then mobilized, taking care that its blood supply was not compromised. This still left a one cm gap that was overcome by performing a hemicircular (180°) myotomy on the lower esophageal pouch approximately 1 cm away from the blind end. A tension free primary esophageal anastomosis was then performed. Post operatively patient developed a stricture which was dilated successfully to 12 Fr (4 mm). No other complications are reported. Conclusion Hemicircular myotomy of the distal esophageal pouch can be employed successfully to achieve primary repair in cases of long gap esophageal atresia. This technique does not require full circumferential mobilization of lower pouch as required with full circular myotomy and has less risk of compromising blood supply to the distal esophageal pouch decreasing risks of anastomotic leak, failure and esophageal motility of lower pouch.

A new esophageal elongation technique for long-gap esophageal atresia: in vitro comparison of myotomy techniques

Complications such as stricture, leakage, recurrent tracheoesophageal fistula and mucosal pouch are commonly seen in myotomy techniques used for long-gap esophageal atresia (LGEA) treatments. Therefore, we think that there is a clear need for other techniques which would enable us to create more robust and longer esophagus in such cases. In this study, we reviewed multiple V-myotomy (VM) technique and the differences of the said technique with Livaditis circular myotomy (LM) and Kimura spiral myotomy (KM) techniques using literature as an aid. 21 esophagus samples from 21 male lambs aged 12months were used in vitro for the study. All esophageal samples were matched to have a length of 120mm. Samples were divided into 3 groups of 7 and VM, LM and KM techniques were used in each group, respectively. Post-op esophagus lengths, elongation amount with each incision and perforation pressures were measured. Post-op esophageal lengths were measured as 227, 210 and 200mm for VM, LM and KM, respectively. Elongation amount per incision was measured as 5.1, 4 and 3.34mm, again in previous order of VM, LM, and KM. Finally, perforation pressure following VM, LM, and KM was measured as 460, 400, and 410mmHg. VM was found to significantly increase total esophagus length and elongation per incision over LM and KM. In addition, VM was also shown to have a higher perforation pressure. Although in vivo live animal studies are required, we can say that VM can be used to create longer and robust esophagus.

Long-term efficacy of peroral endoscopic circular myotomy and full-thickness myotomy on treatment of achalasia of cardia

Objective To compare the long-term efficacy and complications of peroral endoscopic circular myotomy and full-thickness myotomy for patients with achalasia of cardia. Methods A retrospective analysis was performed on the data of 53 patients with achalasia of cardia, who underwent peroral endoscopic myotomy in the First Affiliated Hospital of Zhengzhou University from June 2012 to December 2014 and were followed-up regularly.Twenty-one patients underwent circular myotomy, and the other 32 patients underwent full-thickness myotomy. The postoperative long-term efficacy and gastroesophageal reflux complications of the two groups were compared. Results The effective rate of the circular myotomy group and the full-thickness myotomy group was 90.5% (19/21) and 100.0% (32/32), respectively(P=0.152). There were no significant differences between the two groups on postoperative Eckardt scores, lower esophageal sphincter pressure and 4 s integrated relaxation pressure(P>0.05). The incidence of clinically relevant gastroesophageal reflux of full-thickness myotomy group was higher than that of circular myotomy group (40.6% VS 14.3%, χ2=4.174, P=0.041). Conclusion The long-term efficacy of circular myotomy is similar to that of full-thickness myotomy, but the incidence of clinically relevant gastroesophageal reflux is higher in full-thickness myotomy. Key words: Achalasia, cardia; Peroral endoscopic myotomy; Circular myotomy; Full-thickness myotomy; Long-term efficacy

A Retrospective Study of Peroral Endoscopic Full-Thickness Myotomy in Patients with Severe Achalasia.

Selective circular myotomy (CM) is recommended in peroral endoscopic myotomy (POEM) for achalasia, but completeness of myotmoy is the prerequisite for excellent long-term results of conventional surgical myotomy. The aim of our study was to compare the efficacy and safety between peroral endoscopic full-thickness and simple CM for the treatment of severe achalasia. A total of 123 severe achalasia patients who underwent POEM from August 2011 to May 2013 were included. They were divided into circular or full-thickness myotomy (FTM) groups according to the depth of myotomy. Demographics, Eckardt score, procedure-related parameters, perioperative adverse events, pre- and postoperative esophageal diameter, esophageal manometry, and follow-up results were retrospectively collected and compared between the two groups. All the 123 patients underwent POEM successfully, and the mean operation time was significantly shorter in FTM group compared with CM group (57.4 ± 8.2 minutes versus 63.2 ± 12.3 minutes, P < .05). There was no significant difference between the two groups in terms of treatment success, pre- and postoperative Eckardt score, esophageal diameter, esophageal manometry, and perioperative adverse events (P > .05). Twenty-four-hour pH monitoring was performed in 19 patients (11 in FTM, 8 in CM). Although no statistical difference was detected in rate of abnormal esophageal acid exposure between groups, this rate was higher in FTM group than CM group (60% versus 40%, P > .05). Treatment efficacy in short-to-medium term are comparable between circular or FTM. FTM significantly reduce the operative duration, but it may increase potential risk of gastroesophageal reflux disease incidence.

Successful peroral endoscopic myotomy performed in Endoscopy Department as a radical, long-term treatment for esophageal achalasia - the Greek experience.

IntroductionPeroral endoscopic myotomy (POEM) has been considered as a minimal-invasive, innovative technique for long-term treatment of all types of esophageal achalasia and other esophageal motility disorders.Patients and methodsWe report on 20 consecutive Greek patients with manometrically proved esophageal achalasia (14 patients with type I, 4 with type II, 2 with type III, and 4 with sigmoid esophagus), with an age range of 32–92 years, mean age 59 years, 12 males, successfully treated by POEM from 2013 to 2015. The Eckardt score was 7–12 (type III). Seventeen (85%) POEM procedures were performed in the Endoscopy Department, according to a previous study. During POEM, CO2 insufflation was mandatory, while the Triangle Tip knife was the only knife used in all procedures. Eckardt score, esophagogram and manometry before and after performing POEM were used for evaluation of our results. The follow-up period was 6 months to 3 years.ResultsSelective circular myotomy, 10–13 cm in length, was successfully completed in all patients without severe acute or late complications. Three patients (15%) showed moderate pneumomediastinum and pneumoperitoneum, which was successfully managed by abdominal needle drainage during the procedure. One patient showed mild pleural collection, and in one patient the clip–endoloop technique was used to successfully close the mucosal entry after the completion of POEM. The outcome was uneventful without any further clinical consequences. No other short- or long-term serious complications were reported. Patients were discharged after 1–3 days of hospitalization. Six months to 3 years after the POEM procedure, all patients were alive; the majority (90%) had complete clinical improvement, while two patients with sigmoid-type achalasia showed moderate-to-significant clinical improvement. Erosive esophagitis was reported in 15%.ConclusionOur results are in accordance with international data, and proved the safety and efficacy of the POEM technique for radical long-term treatment of all types of achalasia, including end-stage sigmoid-type achalasia, in the Endoscopy Department. However, long-term follow-up is necessary and awaited.

Clinical Outcomes and Safety of Partial Full-Thickness Myotomy versus Circular Muscle Myotomy in Peroral Endoscopic Myotomy for Achalasia Patients.

Background. Here we aimed to evaluate and compare the efficacy and safety between partial full-thickness myotomy and circular muscle myotomy during POEM procedure in achalasia patients. Methods. Clinical data of achalasia of cardia (AC) patients who underwent POEM in our center during January 2014 to January 2015 was collected (34 cases). 19 patients who received partial full-thickness myotomy were assigned to group A and 14 patients who received circular muscle myotomy were assigned to group B. The procedure-related parameters between the two groups were compared. Symptom relief rate and postprocedure manometry outcomes were compared to evaluate the efficacy. Procedure-related adverse events and complications were compared to evaluate the safety. Results. (1) Mean operation times were significantly shorter in group A than group B (62.42 ± 23.17 vs 87.86 ± 26.44 min, p < 0.01). (2) Symptom relief rate and postprocedure manometry outcomes had no statistical differences when compared between the two groups (all p > 0.05). (3) Comparison of procedure-related adverse events and complications had no statistical differences (all p > 0.05). Conclusion. Partial full-thickness myotomy had no significant differences in efficacy or safety with circular myotomy, but partial full-thickness myotomy significantly reduced the procedure time.

PTH-041 Per Oral Endoscopic Myotomy: First UK Experience

Introduction Per-oral endoscopic myotomy (POEM) has been adopted as a minimally invasive treatment option for achalasia. The first case of POEM was performed at King’s College Hospital in late 2013. Here we present our initial case series with video demonstration of technique. Methods Prospective data was collected for consecutive patients undergoing POEM including demographics, procedure technique, the use of Endoluminal Functional Lumen Imaging Probe (EndoFLIP) and adverse events. Follow up data at 3 months and 12–24 months post-POEM including Eckardt scores and lower oesophageal sphincter integrated resting pressure (IRP-4s) were compared with pre-POEM findings. Post-POEM Gastro-oesophageal Reflux Health-Related Quality of Life scale (GORD-HQL) was recorded. Statistical analysis was achieved using Wilcoxon matched-pairs signed rank test. Results POEM was performed in 33 patients (12 F, age 49.5±13.25 years). Pre-operative high-resoloution manometry confirmed type II achalasia in all patients. 19 patients had previous treatment (Botulinum n = 8, Pneumatic dilatation n = 10, Heller myotomy n = 5, POEM n = 1, >1 treatment n = 2). Median pre-POEM Eckardt Score 8, range 3–12. Median gastric and oesophageal myotomy was 3 cm (range 2–4) and 12 cm (range 5–16) respectively with a selective circular myotomy in all cases and a posterior approach in n = 5. There was significant reduction in post-operative Eckardt score at 3 months Median 0, range 0–6 (p EndoFLIP Intra-operative EndoFLIP measurements before and after myotomy have been implemented to aid confirmation of adequate myotomy (Figure 3). Adverse Events One patient underwent single clip displacement and was replaced at gastroscopy day 1 post POEM. There were no cases of perforation, infection or major bleeding. Gastro-oesophageal reflux Post-POEM GORD-HQL score was collected in 26 patients with a median score of 2.5, range 0–31. Two cases of reflux (positive 24 hr pH at 3 months) were identified and successfully managed with maintenance proton pump inhibitor. Conclusion POEM was performed successfully in 33 patients in whom 57.5% had prior endoscopic or surgical treatment representing a potentially more challenging patient population. This study is in line with international consortia and ASGE findings1 that POEM is a safe and efficacious procedure for the treatment of achalasia for both short term and sustained symptomatic benefit. Reference 1 Stavropoulos S, Desilets D, Fuchs KH et al; Per-oral endoscopic myotomy white paper summary; Gastrointestinal Endoscopy. 2014;1:1–15. Disclosure of Interest None Declared

Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes.

Gastroparesis is a poorly understood, chronic, debilitating motility disorder with very limited medical therapeutic options. Gastric peroral endoscopic pyloromyotomy (G-POEM) is an emerging novel endoscopic technique as an incisionless pyloroplasty for refractory cases. Effective information of G-POEM on different types of gastroparesis is sparse. Cases of G-POEM using selective circular myotomy as a salvage therapy for refractory symptoms were retrospective studied. The G-POEM procedures were performed by a single expert endoscopist under a certain protocol. Gastroparesis Cardinal Symptoms Index (GCSI) and gastric emptying scintigraphy (GES) were evaluated before and after the procedure. Procedures related adverse event were also recorded. All procedures were successfully completed without complications. Each case in this series was different in demography and etiology of gastroparesis, namely postsurgical, postinfectious, and idiopathic gastroparesis in an elderly male and two young female adults. All cases were refractory to conventional treatment but demonstrated obvious success after G-POEM as a salvage therapy both clinically and on GES. G-POEM as a salvage therapy improves symptoms and gastric emptying in patients with different types of refractory gastroparesis. Our cases are also the firsts to show success of G-POEM in postinfectious gastroparesis and in elderly male patient. More data are needed to determine which subgroup of patients would benefit most from this novel procedure.

Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease.

AIMTo compare long-term occurrence of gastroesophageal reflux disease (GERD) between two different types of peroral endoscopic myotomy (POEM) for achalasia.METHODSWe included all patients with achalasia who underwent POEM at our hospital from August 2011 to October 2012 and had complete GERD evaluation with ≥ 3 years of follow-up. They were divided into circular or full-thickness myotomy groups according to the depth of myotomy. Demographics, Eckardt score, manometry results, 24-h pH monitoring, and GERD symptoms were recorded and compared between the two groups.RESULTSWe studied 56 patients (32 circular myotomy and 24 full-thickness myotomy) with complete GERD evaluation. There was no significant difference between the two groups in terms of treatment success (defined as Eckardt score ≤ 3), postoperative Eckardt score, mean basal lower esophageal sphincter pressure, and 4-s integrated relaxation pressure (4sIRP). Postoperative abnormal esophageal acid exposure was found in 25 patients (44.6%). A total of 13 patients (23.2%) had GERD symptoms and 12 had esophagitis (21.4%). Clinically relevant GERD (abnormal esophageal acid exposure associated with GERD symptoms and/or esophagitis) was diagnosed in 13 patients (23.2%). Multivariate analysis revealed that full-thickness myotomy and low level of postoperative 4sIRP were predictive factors for clinically relevant GERD.CONCLUSIONEfficacy and manometry are comparable between achalasia patients treated with circular or full-thickness myotomy. But patients with full-thickness myotomy and low postoperative 4sIRP have more GERD.

180 PerOral Endoscopic Myotomy for Severe Achalasia: the Comparison of Full-Thickness Myotomy and Circular Myotomy

Selective circular myotomy involving the internal circular muscular fibers and preserving the longitudinal outer muscular fibers was proposed for the treatment of achalasia. However, completeness of myotomy is a prerequisite for the excellent long-term result of conventional surgical myotomy. Our study aims to compare the efficacy and safety of full-thickness peroral endoscopic myotomy (POEM) and circular myotomy for the patients with severe achalasia (Patients with Eckardt ≥6, esophgageal diameter ≥6 or sigmoid-type esophagus).

Peroral endoscopic myotomy for achalasia in patients aged ≥ 65 years.

To investigate the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia in patients aged ≥ 65 years. From November 2011 to August 2014, 15 consecutive patients (aged ≥ 65 years) diagnosed with achalasia were prospectively recruited and all underwent POEM at our institution. Eckardt score, lower esophageal sphincter (LES) pressure, esophageal diameter, SF-36 questionnaire, and procedure-related complications were used to evaluate the outcomes. All 15 patients were treated successfully by POEM, with a median operation time of 55 min. Median myotomy length was 10 cm. Three patients underwent circular myotomy and 12 full-thickness myotomies. Symptoms remitted in all cases during post-POEM follow-up of 6-39 mo. Eckardt score reduced significantly (pre-operation vs post-operation: 8.0 vs 1.0, P < 0.05). Median LES pressure decreased from 27.4 to 9.6 mmHg (P < 0.05). Median diameter of the esophagus was significantly decreased (pre-operation vs post-operation: 51.0 mm vs 30.0 mm, P < 0.05). Only one patient had reflux, which was resolved with oral proton pump inhibitors. No serious complications related to POEM were found. The quality of life of the 15 patients improved significantly after POEM. POEM is a safe and effective technique for treatment of achalasia in patients aged ≥ 65 years, with improvement in symptoms and quality of life.

Peroral endoscopic myotomy for treatment of achalasia in children and adolescents

BackgroundPeroral endoscopic myotomy (POEM) is a novel endoscopic technique for treatment of achalasia (AC) and has shown exciting results in adults. However, little is known about the safety and efficacy of POEM in children and adolescents. Herein we report our preliminary results of POEM for children and adolescents with AC. MethodsPOEM was performed in 9 consecutive patients with AC, whose age ranged from 10 to 17years. After submucosal injection, a submucosal tunnel was created. Endoscopic myotomy of muscle bundles was then achieved under direct vision. The mucosal entry was closed by several clips. A validated clinical symptom score (Eckardt score), LES pressure, esophageal diameters and procedure-related complications were used to evaluate the outcomes. ResultsAll 9 patients underwent POEM successfully. Mean operation time was 56.7minutes. Mean myotomy length was 8.3cm. Among them, 4 patients underwent circular myotomy and 5 underwent full-thickness myotomy. Symptoms remitted in all of the cases during a follow-up of 3–30months, Eckardt score was significantly reduced (preoperation vs postoperation, 7.0±1.9 vs 0.8±0.8, P<0.05). Mean LES pressure decreased from 26.8mm Hg to 9.1mm Hg. Mean diameter of esophagus was dramatically decreased (preoperation vs postoperation, 50.6±4.9mm vs 29.6±3.7mm, P<0.05). No serious complications related to POEM were encountered. ConclusionsOur initial experience suggests that POEM is a safe and effective method for treatment of achalasia in children and adolescents. Further evaluation and long-term data are mandatory for a more confirmed conclusion.

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video)

Per-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure. Each patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively. Patients undergoing POEM procedures are preoperatively prepared by taking Nystatin swish-and-swallow for 3 days, 24 h of clear liquid diet, and 12 h of NPO. Preoperative antibiotics are given. Under general anesthesia and with the patient in the supine position, endoscopy with CO2 insufflation is prepared. Special endoscopic instruments and electrocautery settings are required to perform the POEM procedure, as illustrated in the slides. POEM is performed in six key/critical steps: (1) diagnostic endoscopy; (2) taking measurements; (3) esophageal mucosotomy creation; (4) submucosal tunneling; (5) selective circular myotomy of the anterior lower esophageal sphincter; and (6) closure of the mucosotomy. According to our protocol, all patients get an esophogram the next morning after surgery prior to discharge. The patient receives objective testing (HRM with 24 PH Impedance test, EGD, and timed-barium swallow) 6 months postoperatively. In six key steps, POEM can be accomplished as described in the video.

Experience with Livaditis circular myotomy in management of long gap TEF

Management of long gap oesophageal atresia with tracheoesophageal fistula (OA TEF) is challenging. Various intra-operative and pre-operative manures have been described to tackle this challenge. We reviewed our experiences with livaditis circular myotomy. The aim of this study was to evaluate long-term outcomes in cases of long gap OA TEF managed primarily with livaditis circular myotomy. This is a cross-sectional study including cases of long gap oesophagus managed by livaditis circular myotomy between January 1998 and October 2012. Their case records were evaluated for operative and post-operative data. The anthropometric data of these cases were collected. All these cases were subjected to barium swallow and manometry. Those cases with other associated neurological anomalies, multiple congenital anomalies, parents refusing consent for the study, less than 6 months of follow up or incomplete data were excluded from the study. Out of the total of 109 patients of OA TEF managed, long gaps OA TEF were 37. Out of the 37 cases, 13 were managed by primary repair with livaditis circular myotomy. Of these 13 cases, 11 formed the study group. Mean age at evaluation was 36 ± 9 months. Mean age at primary surgery was 3 ± 2.5 days of life. Minor leak in the immediate post-operative period was present in 2/11 cases. Manometry was done in all the cases and revealed motility disorder in the form of un-coordinated contraction in 4/11 cases. Remaining 7/11 cases were normal. Livaditis circular myotomy is a viable option in the management of long gap OA TEF with good comparable long-term results.

Miotomía endoscópica por vía oral de espesor total y parcial. Estudio de factibilidad en un modelo animal

Peroral endoscopic myotomy has recently been developed and performed on patients with good results.To evaluate the technical feasibility of peroral endoscopic full-thickness and partial thickness myotomy in a porcine model.Eighteen criollo pigs were randomly assigned to 2 groups: group A (partial-thickness myotomy) and group B (full-thickness myotomy). The mucosal defect proximal to the myotomy site was left open. On the seventh postoperative day the pig was euthanized and follow-up surgical exploration was performed. The duration of each procedure, postoperative progression of the animal, complications, and anatomopathologic findings were registered.The procedure was viable in all the pigs. The mean surgery duration was 81±35.3min (group A 51.11±11.12, group B 111±22.61; P<.05). The main complication during myotomy was subcutaneous emphysema (16%). The histopathologic study of the group A surgical specimens reported complete circular myotomy in all cases, and complete circular and longitudinal myotomy was reported in 100% of the group B sample.The endoscopic myotomy technique is feasible. Endoscopic partial-thickness myotomy was associated with shorter surgery duration and better results during the intraoperative period and the 7-day follow-up.

Peroral endoscopic full and partial-thickness myotomy. A viability study in an animal model

BackgroundPeroral endoscopic myotomy has recently been developed and performed on patients with good results. AimsTo evaluate the technical feasibility of peroral endoscopic full-thickness and partial thickness myotomy in a porcine model. Material and methodsEighteen criollo pigs were randomly assigned to 2 groups: group A (partial-thickness myotomy) and group B (full-thickness myotomy). The mucosal defect proximal to the myotomy site was left open. On the seventh postoperative day the pig was euthanized and follow-up surgical exploration was performed. The duration of each procedure, postoperative progression of the animal, complications, and anatomopathologic findings were registered. ResultsThe procedure was viable in all the pigs. The mean surgery duration was 81±35.3min (group A 51.11±11.12, group B 111±22.61; P<.05). The main complication during myotomy was subcutaneous emphysema (16%). The histopathologic study of the group A surgical specimens reported complete circular myotomy in all cases, and complete circular and longitudinal myotomy was reported in 100% of the group B sample. ConclusionsThe endoscopic myotomy technique is feasible. Endoscopic partial-thickness myotomy was associated with shorter surgery duration and better results during the intraoperative period and the 7-day follow-up.

Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia

Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications. We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device. An anterior esophageal 2cm mucosectomy is created 7-10cm proximal to the gastroesophageal junction after a submucosal wheal is raised. A submucosal tunnel is created and extended to 2cm on the gastric cardia. A selective circular myotomy is performed. The mucosectomy is closed using endoscopic clips. An inadvertent full-thickness esophagotomy was created while performing the mucosotomy on an inadequate submucosal wheal. We were able to resume the POEM technique at the initial esophagotomy site. There was a discussion to convert to laparoscopy. However, as we succeeded in creating the tunnel, we continued with the POEM technique. After the selective myotomy was completed, we used an endoluminal suturing device (Overstitch, Apollo Endosurgery, Austin TX) to close the full-thickness esophagotomy in two layers (muscular, mucosal). A covered stent was not an option because the esophagus was dilated, which precluded adequate apposition. The patient had an uneventful postoperative course. At 9-month follow-up, had excellent palliation of dysphagia without reflux. This case demonstrates the importance of identifying extramucosal intrathoracic anatomy, thus emphasizing the need for an experienced surgeon to perform these procedures, or at a minimum to be highly involved. Raising an adequate wheal is crucial before mucosectomy. Inadequacy of the wheal may reflect local esophageal fibrosis. If this fails at multiple locations in the esophagus, it may be prudent to convert to laparoscopy. This case also demonstrates the need for advanced flexible endoscopic therapeutic tools and a multidisciplinary approach to manage potential complications.