Esophageal Myotomy Research Articles

Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature.

Background: Esophageal thoracic diverticular disease is a rare condition resulting from multiple etiologies. Surgical management is recommended when symptomatic. Traditionally, a thoracotomy was considered the standard approach; however, the use of minimally invasive approaches has been associated with improved outcomes. Methods: We retrospectively reviewed a single surgeon's experience with minimally invasive esophageal diverticulectomy. Results: Fifteen patients with symptomatic esophageal diverticular disease underwent minimally invasive diverticulectomy between 2005 and 2018. Most patients (86.7%) had epiphrenic diverticula and 53.3% underwent a video-assisted thoracoscopic surgery approach. All patients had a diverticulectomy, while 14 patients (93.3%) also had an esophageal myotomy. Three patients (20%) underwent an extended myotomy, 4 patients (26.7%) underwent a concomitant fundoplication, and 2 patients (13.3%) underwent a concomitant paraesophageal hernia repair. Median length of hospital stay was 2 days (range, 1-16 days). There were no mortalities. Two patients (13.3%) were readmitted with delayed esophageal leaks. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient presented with recurrent disease 5 years after his initial operation. Conclusions: In experienced hands, a minimally invasive diverticulectomy is safe, effective, and associated with excellent patient outcomes. A minimally invasive approach should be performed when possible and should be tailored to the individual patient's disease and preoperative workup.

Treatment of esophageal diverticula in uniportal video-assisted thoracoscopic surgery

Esophageal diverticulum is a rare disease caused by impaired esophageal motility. It may present with disorders like pain, heartburn, dysphagia, episodes of food regurgitation and halitosis, but often the patients are asymptomatic. Diagnosis is based on the esophagogram with barite meal, gastroscopy and esophageal manometry. The diverticula can be classified according to the site of onset in the esophagus: diverticula of the distal third (epiphrenic, 20%), mediothoracic or mediastinal (10%) and proximal diverticula (Zenker diverticula, 70%). Traditionally, surgical treatment involves a thoracotomy approach that allows diverticulectomy and esophageal myotomy. In our centre, we started to use the uniportal video-assisted thoracoscopic surgery (VATS) approach for the treatment of esophageal diseases, both neoplastic and benign. In our preliminary experience with uniportal VATS diverticulectomy, we obtained good results in terms of effectiveness, reduction in hospitalization time, complications, pain control and early recovery of patient’s daily activities.

Oesophagocardiomyotomy for Achalasia Cardia via Thoracotomy in a Teaching Hospital in Ghana: A 5-Year Retrospective Review

Achalasia cardia is a primary oesophageal motility disorder of unknown aetiology characterized manometrically by insufficient relaxation of the lower oesophageal sphincter (LES) and loss of oesophageal peristalsis; radiographically by aperistalsis, oesophageal dilation with minimal LES opening, bird-beak appearance, poor emptying of barium; and endoscopically by dilated oesophagus with retained saliva, liquid and undigested food particles in the absence of mucosal stricturing or tumour. Achalasia cardia patients usually present with difficulty in swallowing both solids and liquids and this may be associated with regurgitation, heartburn and chest pains. Treatment options include medical or pharmacologic therapy, botulinum toxin injection, pneumatic dilation and oesophagocardiomyotomy or the Heller myotomy with or without antireflux procedure and recently the POEM (Perioral oesophageal myotomy). Herein, we present our experience with four cases managed surgically via thoracotomy without antireflux surgery over a 5-year period, from January 2015 to June 2019 at the Komfo Anokye Teaching Hospital, the second largest teaching hospital in Ghana.

A Novel Indication of Per Oral Esophageal Myotomy in the Management of a Lower Esophageal Diverticulum

A Novel Indication of Per Oral Esophageal Myotomy in the Management of a Lower Esophageal Diverticulum

Optimal surgical intervention for achalasia: laparoscopic or robotic approach.

Laparoscopic esophageal myotomy is the standard surgical intervention for achalasia. Compared to standard laparoscopic techniques, use of the robot has theoretical advantages of improved visualization and dexterity. We evaluated the University of Arizona's experience with the two alternatives to compare outcomes. Patients who underwent either laparoscopic or robot-assisted myotomy were identified from a retrospective database from 1/1/2006 to 12/31/2015. Patient demographics, prior treatment, intra-operative complications, operative time, post-operative length of stay and complications, and long-term results were compared between the two groups. We identified 35 laparoscopic and 37 robot-assisted Heller myotomies performed by multiple surgeons. Patient demographics were similar between the two groups with no statistical difference in age, gender, previous operations, pre-operative Botox or dilation treatment, or pre-op Eckardt score. In univariate analysis, the patients with the robotic procedure received a longer myotomy (5.85cm vs. 5.56cm for esophageal and 2.92cm vs. 2.68cm for gastric) and had a lower post-operative Eckardt score (0.51 vs. 1.09). A trend toward lower incidence of recurrent achalasia symptoms was found in the robotic group (0 patient vs. 4 patients) compared with those who had laparoscopic surgery (p < 0.05). Multivariate analysis showed that a longer gastric myotomy was associated with a lower recurrence rate (p = 0.0002). Both laparoscopic and robot-assisted Heller myotomy can provide definitive treatment of achalasia with good results and few complications. The mechanical advantage provided by the robotic approach may improve outcomes by providing a more complete myotomy and durable long-term result.

Management of achalasia cardia: Expert consensus statements.

Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per-oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short-term to mid-term follow-up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.

Tu1195 LONG-TERM OUTCOMES OF PER-ORAL ENODOSCOPIC MYOTOMY IN ACHALASIA PATIENTS WITH A MINIMUM FOLLOW-UP OF 4 YEARS: A MULTICENTER STUDY

Per-oral endoscopic myotomy (POEM) is associated with 82-100% short-term clinical response in patients with achalasia. However, durability of response is not well known as long-term data is limited. To study (1) clinical outcomes of patients with a minimum post-POEM follow-up of 4 years; and (2) factors associated with long−term clinical failure after POEM. We conducted a retrospective review of consecutive patients with achalasia who underwent POEM with a minimum follow-up of 4 years at 11 tertiary centers (2 US, 7 Europe, 2 Asia). Clinical response was defined by an Eckardt score of ≤3. A total of 146 patients (79 females (54%); mean age 49.8 yr.) with achalasia (41 type I, 70 type II, 9 type III and 26 with unspecified type) were included. Of these, 29 (19.9%) patients had prior pneumatic dilatation, 13 (8.9%) had botulinum toxin injection and 7 (4.8%) had a prior Heller myotomy. Anterior myotomy was performed in 77.8% and full-thickness LES myotomy was carried in 52.4% of patients. The mean length of esophageal myotomy was 8.5±2.5 cm and length of gastric myotomy was 3.2±1 cm. A total of 8 (5.5%) adverse events occured (6 mucosotomy, 2 pneumothorax). The median follow-up duration was 55 months (IQR 49.9-60.6). Clinical success was seen in 96.4% (136/141), 95.9% (118/123), 94.1% (127/135), 95.9% (118/123) and 95.2% (139/146) at 6 months, 12 months, 24 months, 36 months and ≥ 48 months, respectively. Of the 7 patients who experienced clinical failure at 4 years, 5 experienced initial response and then had a late (after 6 months) recurrence of symptoms. The mean Eckardt score decreased from 7.5±1.7 to 1.28±1.29 (p < 0.001) and 4sIRP pressure from 28.7 ± 11 to 10.1 ± 7.1 mmHg (P<0.001). On univariable analysis, male gender (OR 7.6, p 0.062), a sigmoid esophagus (OR 2.33, p 0.45), prior Heller myotomy (OR 3.7, p 0.26) and type III achalasia (OR 2.73, p 0.37) were associated with long-term treatment failure, although the association was not statistically significant. Four patients with clinical failure underwent re-treatment: 1 had a repeat POEM and 3 had a pneumatic balloon dilation. Clinical response was attained in 3 of the 4 patients. Symptomatic reflux was seen in 45/140 (32.1%) patients after POEM. Post-POEM pH monitoring testing was completed in 80 patients, of whom 38 (47.5%) had abnormal acid exposure. Reflux esophagitis was noted in 22 (16.8%) of the 131 patients who had an EGD after POEM. Regarding PPI use, 48 (35.3%) patients are currently using PPI on a daily basis and 15 (11%) occasionally, whereas 73 (53.7%) are not using the medication. POEM is a durable and safe procedure which provides high initial clinical success and excellent long-term outcomes. Less than 5% of patients who achieved clinical response at 6 months had recurrent symptoms at 4 years.Table 2. Univariable logistic regression analysis of factors associated with long-term clinical failure (≥ 4 years after POEM, n=7)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Application value of the adhesive suspension of left lateral lobe of liver in transumbilical single-port laparoscopic left upper abdominal surgery

Objective To investigate the application value of the adhesive suspension of left lateral lobe of liver in transumbilical single-port laparoscopic left upper abdominal surgery. Methods The retrospective cross-sectional study was conducted. The clinical data of 112 patients who underwent single-port laparoscopic left upper abdominal surgery in the Shengjing Hospital of China Medical University between January 2010 and October 2016 were collected. Patients underwent single-port laparoscopic left upper abdominal surgery, and intraoperative surgical fields were exposed through adhesive suspension of left lateral lobe of liver. Observation indicators: (1) intraoperative situations: surgical completion, surgical procedures, time of liver adhesive suspension, total operation time and intraoperative liver adhesive suspension-related complications; (2) postoperative situations: pre- and post-operative alanine transaminase (ALT) and aspartate transaminase (AST) levels, hospital expenses and duration of hospital stay; (3) follow-up: number of patients with follow-up, follow-up time, complications during follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to June 2017. Measurement data with normal distribution were represented as ±s. Repeated measurement data were analyzed using the repeated measures ANOVA. Results (1) Intraoperative situations: 112 patients underwent successfully single-port laparoscopic left upper abdominal surgery, without conversion to multi-port surgery or open surgery. Of 112 patients, 30, 23, 13, 11, 11, 10, 3, 3, 3, 3, 1 and 1 underwent radical resection of gastric cancer, partial gastrectomy, esophageal Heller myotomy + Dor fundo-plication, subtotal gastrectomy, resection of body and tail of pancreas, paraoesophageal hiatal hernia repair + fundoplication, total gastrectomy, splenectomy, splenectomy + devascularization, pancreatic tail resection, simple fundoplication and splenic artery aneurysm resection, respectively. Time of liver adhesive suspension and total operation time in 112 patients were respectively (1.4±0.4)minutes and (192.0±91.3) minutes. There was no hepatic laceration, hepatic subcapsular hematoma and other complications. (2) Postoperative situations: of 112 patients, preoperative ALT and AST levels of 6 patients were mildly elevated, postoperative ALT and AST levels in 2 of 6 patients returned to normal, that in 1 of 6 patients were elevated at day 1 postoperatively and returned to normal at day 3 postoperatively, and that in 2 of 6 patients remained mildly elevated at week 1 postoperatively; preoperative ALT and AST levels of 106 patients were normal, ALT and AST levels in 31 of 106 patients were elevated at day 1 postoperatively (that in 28 patients returned to normal within week 1 postoperatively, and that in 3 patients remained mildly elevated), and that in 75 of 106 patients returned to normal. ALT and AST levels of 112 patients were (16±11)U/L, (18±7)U/L before operation and (31±21)U/L, (34±26)U/L at day 1 postoperatively and (19±17)U/L, (19±12)U/L at week 1 postoperatively, respectively, with statistically significant differences in ALT and AST levels before operation and at day 1 postoperatively (F=36.353, 29.792, P 0.05). Hospital expenses, surgery-related expenses and duration of hospital stay were (45 231±20 440)yuan, (23 511±9 609)yuan and (6.0±1.9)days, respectively. (3) Follow-up: 112 patients were followed up for 1.0-3.0 months, with a median time of 1.6 months. During the follow-up, there were no obvious complications. Conclusion Adhesive suspension of left lateral lobe of liver is simple and safe, with satisfactory exposure effects, and it is suitable for the better operative field exposure in single-port laparoscopic left upper abdominal surgery. Key words: Gastric neoplasms; Left lateral lobe of liver; Suspension, adhesive; Left hypochondriac region; Laparoscopy, single-port

Clinical factors and high-resolution manometry predicting response to surgery for achalasia in children

BackgroundEsophageal achalasia is an uncommon condition in children. Although many interventions exist for the management of this disorder, esophageal (Heller) myotomy offers one of the most durable treatments. Our institution sought to review patients undergoing Heller myotomy concentrating on preoperative clinical factors that might predict postoperative outcomes. Materials and methodsAll patients from January 1, 2007, to December 31, 2016, who underwent surgical treatment for achalasia at our tertiary pediatric hospital were identified and included in the study cohort. Electronic medical records for these patients were reviewed for clinical presentation variables, nonsurgical preoperative treatment, surgical approach, clinical response to surgery, need for postoperative treatment for ongoing symptoms, and high-resolution manometry (HRM) data. ResultsTwenty-six patients were included in the study, and all underwent myotomy with partial fundoplication (median age: 14.4 y [interquartile range 11.6-15.5]). At a median follow-up of 9.75 mo (interquartile range 3.5-21 mo), 16 (61.5%) patients reported good resolution of their dysphagia symptoms with surgery alone. Two patients (7.7%) had perforation of the gastrointestinal tract requiring surgical intervention. Eight patients (30.8%) required additional treatment for achalasia, with 5 (19.2%) of these undergoing additional surgery or endoscopic treatment. Patients who had preoperative dilation did not have good resolution of their dysphagia (n = 2; P = 0.037). Two of four patients undergoing postoperative dilation had preoperative dilation. None of these patients underwent preoperative manometry. There was a statistically significant difference in the ages of patients who required postoperative intervention and those who did not (14.1 versus 15.2 y old, respectively; P = 0.043). In patients who reported improvement of gastroesophageal reflux disease/reflux type symptoms after Heller myotomy, lower esophageal residual pressure (29.1 versus 18.7 mmHg; P = 0.018) on preoperative HRM was significantly higher than in those who did not report improvement after surgery. Higher upper esophageal mean pressure (66.6 versus 47.8 mmHg; P = 0.05) also predicted good gastroesophageal reflux disease/reflux symptom response in a similar manner. ConclusionsCurrent analysis suggests that preoperative dilation should be used cautiously and older patients may have a better response to surgery without need for postoperative treatment. In addition, preoperative HRM can aid in counseling patients in the risk of ongoing symptoms after surgery and may aid in determining if a fundoplication should be completed at the index procedure. Further research is needed to delineate these factors. Level of evidenceLevel III.

Advances in the management of oesophageal motility disorders in the era of high-resolution manometry: a focus on achalasia syndromes.

This corrects the article DOI: 10.1038/nrgastro.2017.132.

An improved laparoscopic technique for myotomy and fundoplication in patients with achalasia

Achalasia is preferentially treated by esophageal myotomy. We present a potentially more secure technique of myotomy and fundoplication incorporating a three-stitch cardiopexy on the right of the esophagus and a left lateral fixation at the angle of His. The process of dissection, fixation and repair is described in detail using intraoperative photographs to illustrate each step. This technique is especially suited to achalasia patients with abnormalities of the hiatal anatomy. This paper offers an improvement to a well-practiced technique, which is presented in significant detail. It is of particular interest as it may improve outcomes for achalasia treatment thanks to a more secure technique.

Robotic Laparoscopic Enucleation of a Giant Lower Esophageal Leiomyoma: Advantages of the Transabdominal Approach

Introduction: Esophageal leiomyomas are the most common benign tumors of esophagus, although rare.1,2 Treatment of esophageal leiomyomas depends on tumor size, location, patient condition, and surgeon experience. For tumors ≤5 cm, transthoracic enucleation is the treatment of choice.3–5 For tumors ≥8–10 cm, termed “giant leiomyomas,” enucleation may still be performed although with an associated higher incidence of both dysphagia after closure of the esophageal muscle defect and reflux if the lower esophageal sphincter is involved.5–8 We present a patient with a giant leiomyoma who underwent robotic laparoscopic enucleation. Case Details: The patient is a 56-year-old female with a body mass index of 32 kg/m2 who presents with 6 months of intermittent chest and epigastric pain and associated dysphagia. Her comorbidities included diabetes, hypertension, and gastroesophageal reflux disease. Esophagogastroduodenoscopy demonstrates external compression of distal esophagus without other intraluminal findings. A subsequent chest computed tomography scan reveals an 8-cm lobular soft tissue mass circumferentially involving the lower esophagus. Endoscopic ultrasound shows a multilobulated hypoechoic mass measuring 8 × 6.2 cm involving 75% of the esophageal circumference. Three distinct lobules were noted as were internal calcifications. Fine-needle aspiration biopsies showed leiomyoma with benign features. Surgical Technique: The patient was positioned supine with both arms extended laterally. The operating table was positioned in steep reverse Trendelenburg and right lateral decubitus. We used four 8 mm robotic trocars, one accessory 11 mm trocar, and a subxyphoid 5 mm skin incision for a Nathanson liver retractor. Upon access to the peritoneum, the gastrohepatic ligament was divided as was the phrenoesophageal membrane. The esophagus was circumferentially dissected from the hiatus. The gastric fundus was mobilized by dividing the short gastric vessels and retrogastric adhesions. The esophagus was enlooped with a Penrose drain to facilitate atraumatic esophageal retraction for further mobilization and mediastinal dissection. The tumor mass was observed and carefully dissected from the esophageal wall and other mediastinal attachments. Once the tumor was fully mobilized from the esophagus, the muscular defect in the esophagus was closed and a contralateral esophageal myotomy was performed. Cruroplasty was performed in a standard manner. Finally, a 270-degree posterior fundoplication was created. The tumor was removed from the abdominal cavity using a nylon-reinforced endobag through a dilated left lateral port site. Results: Our operative time was 132 minutes and the estimated blood loss was 5 mL. The patient was hospitalized overnight and discharged to home on postoperative day 1, on a full liquid diet. She was advanced to a soft diet at 1 week. The patient presented to the outpatient clinic at 2 weeks and 3 months for routine follow-up, and was noted to be doing very well without dysphagia or symptoms of gastroesophageal reflux. Discussion: Our operative technique demonstrates several advantages of the laparoscopic approach for enucleating distal esophageal leiomyomas, even when large. This approach allows direct access to both sides of the esophagus, facilitating the performance of a contralateral myotomy to lower risk of postoperative dysphagia after closure of the esophageal wall muscular defect. Similarly, creation of an antireflux fundoplication is readily performed to minimize risk for postoperative gastroesophageal reflux. In addition, the transabdominal approach for enucleating distal esophageal leiomyoma is more familiar to minimally invasive surgeons and allows a less morbid treatment option to thoracic surgery or esophageal resection. Conclusion: Robotic laparoscopic enucleation of lower esophageal leiomyomas is feasible and safe, even for large tumors. This approach also allows the benefit of concurrent myotomy and antireflux surgery. This technique should be preferred to the usual transthoracic approach when laparoscopic expertise is available. No competing financial interests exist. Runtime of video: 9 mins 20 secs

Does Esophageal Myotomy for Achalasia Increase Body Mass Index in Obese Patients?

Montalvo, Domingo MD; Luo, Ran B. MD; Liu, Shanglei MD; Suzuki, Toshiaki; DeLong, Jonathan C. MD; Jacobsen, Garth R. MD, FACS; Sandler, Bryan J. MD, FACS; Horgan, Santiago MD, FACS Author Information

Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials.

BackgroundAchalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM.MethodsA thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed.ResultsA total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31–0.82; P = 0.009 and OR: 0.47; CI 0.22–0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33–1.19; P = 0.34).ConclusionPD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Treatments for achalasia in 2017: how to choose among them.

To review recent advances in achalasia diagnostics and therapeutics. The cardinal feature of achalasia, impaired lower esophageal sphincter (LES) relaxation, can occur in association with varied patterns of esophageal contractility. The Chicago Classification distinguishes among these as follows: without contractility (type I), with panesophageal pressurization (type II), with premature (spastic) distal esophageal contractions (type III), or even with preserved peristalsis [esophagogastric junction (EGJ) outlet obstruction]. Physiological testing also reveals achalasia-like syndromes that also benefit from achalasia therapies. Coincident with this has been the development of peroral endoscopic myotomy (POEM), an endoscopic technique for performing an esophageal myotomy. Hence, the option now exists to either selectively ablate the LES (pneumatic dilation, laparoscopic Heller myotomy, or POEM) or to ablate the sphincter and create a myotomy along some or the entire adjacent smooth muscle esophagus (POEM). Each achalasia syndrome has unique treatment considerations; type II achalasia responds well to all therapies, whereas type III responds best to POEM. Emerging data support the concept that optimal management of achalasia is phenotype-specific, guided by high-resolution manometry, and, in some instance, functional luminal imaging probe studies. This opinion article reviews the varied characteristic and treatment considerations of achalasia syndromes as currently understood.

Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders.

Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and efficacy, the long-term symptomatic outcomes after the procedure are unknown. Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopyfor objective follow-up. Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4, p<0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6months and maintained at 2years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett's esophagus in one. The patient with Barrett's underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication. POEM resulted in a successful palliation of symptoms in the majority of patients after 5years, though these results emphasize the importance of long-term follow-up in all patients.

Esophagogastric junction outflow obstruction-related functional chest pain treated using robotic-assisted thoracoscopic esophageal myotomy

Elevated relaxation pressure in combination with intact or weak peristalsis characterizes esophagogastric junction (EGJ) outflow obstruction. Symptoms of EGJ outflow obstruction include dysphagia and atypical chest pain. EGJ outflow obstruction can be diagnosed using high-resolution manometry (HRM), but there is a lack of consensus regarding treatment. We present a case report of a 43-year-old man with a history of headache and mitral valve disorder who suffered from intermittent atypical chest pain for 20 years. A diagnosis of EGJ outflow obstruction was made using esophageal HRM. Due to medication intolerance, robotic-assisted esophageal myotomy and Belsey-Mark IV fundoplication were performed. The symptoms went into complete remission and no motility disorders were detected on postoperative HRM. HRM is a useful diagnostic examination for EGJ outflow obstruction. The robotic systems-assisted long segment myotomy may potentially play an important role in the treatment of EGJ outflow obstruction-related functional chest pain.

Per-oral endoscopic myotomy for achalasia.

Symptoms in patients with achalasia are produced by outflow obstruction at the level of the lower esophageal sphincter (LES). As a consequence of neural destruction the LES does not undergo normal swallow-induced relaxation. In addition, the esophageal body loses normal peristaltic function and esophageal emptying is on the basis of gravity. All therapies for achalasia are palliative in that normal LES or esophageal body function cannot be restored. The efficacy of any therapy for achalasia is directly related to its ability to reduce the outflow obstruction at the LES. The three main treatment options are pneumatic dilatation, laparoscopic myotomy and partial fundoplication and per-oral endoscopic myotomy or per-oral esophageal myotomy (POEM). Details of the procedures and outcomes will be discussed.

Efficacy and safety of peroral esophageal myotomy vs laparoscopic Heller’s myotomy for treatment of achalasia: a meta-analysis

Efficacy and safety of peroral esophageal myotomy <i>vs</i> laparoscopic Heller’s myotomy for treatment of achalasia: a meta-analysis

How to Effectively Use High-Resolution Esophageal Manometry

How to Effectively Use High-Resolution Esophageal Manometry