Incomplete Myotomy Research Articles

Cricopharyngomyotomy: Outcomes of flexible endoscopic management of small and medium sized Zenker's diverticulum

BackgroundZenker's diverticulum (ZD) was historically treated with an open transcervical myotomy with diverticulectomy, but endoscopic approaches have gained popularity, though with little recent data. This study aimed to report flexible endoscopic cricopharyngomyotomy (FEC) outcomes, particularly in smaller diverticula. MethodsPatients with ZD treated with FEC at a tertiary center were reviewed. Patients were grouped by diverticulum size: small (sZD)≤1.5 ​cm; medium (mZD) ​> ​1.5 ​cm. ResultsOf 30 patients, median age, BMI, sex, and comorbidities were similar between sZD (n ​= ​18) and mZD (n ​= ​12). Overall, 80.0 ​% had the procedure performed with a needle knife. Median number of clips for mucosotomy closure (5.0[5.0,6.0]vs.7.0[5.0,7.0]clips;p ​= ​0.051), operative time (59.5[51.0,75.0]vs.74.5[51.0,93.5]minutes;p ​= ​0.498), length-of-stay (1.0[1.0,1.0]vs.1.0[1.0,1.0]days;p ​= ​0.397), and follow-up (20.8[1.1,33.4]vs.15.6[5.4,50.4]months;p ​= ​0.641) were comparable. There were no postoperative leaks; incomplete myotomy occurred in one sZD, yielding a clinical success rate of 96.7 ​%. ConclusionsFEC has a high success rate for ZD and an advantage in small diverticula, difficult to treat with stapling or open technique.

Robotic Heller's cardiomyotomy for achalasia: early outcomes for a high-volume UK centre.

Heller's cardiomyotomy (HCM) is the gold standard treatment for achalasia. Laparoscopic HCM has been shown to be effective with low rates of symptom recurrence, though oesophageal mucosal perforation rates remain high. The aim of this prospective case series is to assess the short-term complication rates and perioperative outcomes for the first cohort of patients undergoing robotic-assisted HCM for achalasia in a single high-volume UK centre. Data were collected from a prospective cohort of patients who underwent robotic HCM at a single high-volume UK centre. Outcomes were assessed using the Eckhard score, which was calculated after their routine postoperative clinic appointments. Thirteen patients underwent robotic HCM during the study period; this is the second largest reported case series in the European literature. There were no intraoperative oesophageal perforations. Six patients were discharged as day cases, six patients were discharged on the first postoperative day and one patient's hospital stay was two nights. There was a single perioperative complication of urinary retention. All patients reported improvement of symptoms following their operation, and all had a postoperative Eckhard score of less than 3, indicating their achalasia was in remission. This cohort has demonstrated that robotic HCM has an exceptional safety profile and results in high levels of symptom resolution, even early in the learning curve. The robotic approach may be superior to laparoscopy as it allows more precise identification and dissection of the oesophageal muscle fibres, which likely reduces the risk of inadvertent mucosal damage or incomplete myotomy.

LAPAROSCOPIC EXPLORATION FOR INFANTILE HYPERTROPHIC PYLORIC STENOSIS: AN EXPERIENCE AT TERTIARY CARE HOSPITAL

Objectives: This study aims to share our experience of laparoscopic exploration for infantile hypertrophic pyloric stenosis. Material and methods: This retrospective study was conducted in the Department of Pediatric Surgery, Khyber Teaching Hospital, Peshawar from June 2017 to July 2020. This study includes all patients whose diagnosis of infantile hypertrophic pyloric stenosis (IHPS) was confirmed through ultrasound parameters and laparoscopic pyloromyotomy was performed. Data was retrieved from the laparoscopic surgery record. Retrieved data was tabulated and fed in SPSS 25 for analysis. Results: This study included 42 patients with a mean age of 50.28 ±18.5days and a mean weight of 3.35±0.76 kg. Male patients were 57 % while females were 43 %. The mean time to resuscitate the patient pre-operatively was 34.6±15.4 hours while the mean postoperative hospital stay was 45±12.47 hours. The mean operative time was 31.6±10.4 min. Operative time decreased with time depicting improvement in our learning curve (p=0.004). The method of working instrument placement had no impact on operative time (p=0.337). Meantime to full oral feed was 9.7±5.1 hours. We did not encounter mucosal perforation or incomplete myotomy. No surgery was converted to open. Conclusion: Laparoscopic pyloromyotomy is a safe and effective method of treatment for infantile hypertrophic pyloric stenosis. Keywords: laparoscopic pyloromyotomy, pyloric stenosis, IHPS

Timing of pediatric pyloromyotomy on hospital length of stay

Pyloromyotomy timing is predicated upon correction of electrolyte abnormalities. Among infants who presented with normal electrolytes, we hypothesized that pyloromyotomy the evening of presentation, rather than waiting until morning, would confer shorter length of stay (LOS). This single-center retrospective cohort study included patients who underwent pyloromyotomy from 2012 to 2021. Exposure was time of operation with nighttime considered between the times of 17:00 and 06:59 and daytime between 07:00 and 16:59. A 2:1 daytime to nighttime match was performed among patients who presented with normal electrolytes with Fisher's Exact and Student's t-test for comparisons. Of 520 patients, 15 (3%) underwent pyloromyotomy overnight and were matched to 30 daytime patients. There were no differences in median age (33 days (interquartile range [IQR] 29–44) vs 32 days (IQR 25–44)), male sex (15 (100%) vs 28 (93.3%), or history of prematurity (0 (0%) vs 2 (6.7%)) for nighttime compared to daytime, respectively. Operative outcomes including conversion to open, duodenal perforation, incomplete myotomy, or surgical site infection did not differ between the groups. While the nighttime group had a significantly shorter time from presentation to operating room (OR) than the daytime group (5.3 vs 15.9 h), there were no significant differences in total LOS (45.7 vs 57.3 h, p = 0.13). For infants with hypertrophic pyloric stenosis who present with normal electrolytes, it is safe to offer operation same-day or following a night of hydration. There was no evidence of improved hospital utilization for patients undergoing pyloromyotomy the night of presentation.

Risk factors for clinical failure of peroral endoscopic myotomy in achalasia.

The recent development of per oral endoscopic myotomy (POEM) has been a game changer in the management of patients with achalasia. However, approximately 1 in 10 patients will not experience clinical success. The aim of this mini-review is to describe the current state of knowledge about the risk factors associated with POEM failure for the treatment of achalasia. Suspected risk factors are detailed into pre-, intra-, and post-procedural factors and put into perspective. Pre-procedural factors have been described, such as pre-treatment Eckardt score, previous treatments for achalasia, sigmoid type esophagus, significant esophageal dilatation, non-type II achalasia, young age and long duration of symptoms. An intra-procedural factor, mucosal injury during POEM, has also been associated with POEM failure. The occurrence of post-POEM GERD was identified as a controversial post-procedural factor associated with failure. The presumed mechanisms of POEM failure are incomplete myotomy or ineffective LES disruption, as confirmed by high-resolution manometry. However, when manometry confirms a significant decrease in LES pressure, it is likely that either impaired peristalsis or a morphologic abnormality such as extreme esophageal dilatation or severe tortuosity, which are not treated by POEM, should be suspected. Notably, a recently described adverse effect of POEM is the formation of a pseudo-diverticulum at the site of the myotomy (blown out myotomy). We finally stress the importance of performing a complete workup in case of POEM failure as different mechanisms of POEM failure should lead to different management.

Recurrence after Zenker's peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side.

Video 1A case of recurrence after Z-POEM because of incomplete myotomy on the esophageal side.

Endoscopic diverticulotomy for Killian-Jamieson diverticulum: mid-term outcome and description of an ultra-short tunnel technique.

Background and study aims Killian-Jamieson Diverticulum (KJD) is a rarer and more recently described upper pharyngeal diverticulum than Zenker’s diverticulum (ZD). KJD is more difficult to manage than ZD because it tends to extend lower into the upper mediastinum and the diverticulum neck is in close proximity to the recurrent laryngeal nerve. There is limited literature on KJD management and transcervical surgical diverticulectomy is the mainstay of therapy. Patients and methods Here we describe two methods of endoscopic diverticulotomy to treat KJD – direct and tunneling diverticulotomy (with hypopharyngeal tunnel or ultra-short tunnel – the latter being our preferred technique). Results This was a retrospective study including 13 consecutive patients between March 2015 and April 2018. Three patients received direct and 10 received tunneling diverticulotomy (7 with the hypopharyngeal tunnel and 3 with the ultra-short tunnel). All procedures were completed in 16 to 52 minutes. There was no incidence of bleeding, mediastinitis, or sign of recurrent laryngeal nerve injury. At follow up of 9 to 79 months (median 33), the clinical success rate was 92 % (12/13); 11 patients had complete symptom resolution (post-operative symptom score = 0) and one patient had near-complete symptom resolution (occasional residual dysphagia). One patient receiving direct myotomy had limited symptom relief (frequent residual dysphagia and occasional residual regurgitation), possibly related to incomplete myotomy. Conclusions Endoscopic tunneling diverticulotomy is a feasible, safe, and effective method to treat KJD.

Вибір методу лікування новонароджених із гіпертрофічним пілоростенозом

Hypertrophic pyloric stenosis (HPS) remains the main cause of projectile vomiting in newborns. During many decades the open pyloromyotomy was the main method of treatment in children with HPS due to the excellent results and low frequency of complications. After applying the laparoscopic pyloromyotomy, this approach gradually became accepted by pediatric surgeons. Regarding advantages and disadvantages of laparoscopic pyloromyotomy compared to conventional pyloromyotomy the literature data had a contradictory character. The aim is to analyze our own experience in the treatment of children with HPS using traditional and minimally invasive techniques. Materials and methods. This study based on the results of the treatment of 98 children, which were operated with pyloric stenosis during 2009–2020 years. Diagnosis was established on the results of clinical, laboratory investigation, and ultrasonographic data. Surgery was applied after correction of electrolytes disturbances, but a type of approach (open or laparoscopic) was chosen by surgeon. With the aim to evaluate the results the methods of variative statistic, parametric and nonparametric evaluation were applied. Results. Open pyloromyotomy was applied in 76 (77.6%) and laparoscopic – in 22 (22.4%) of children. Complications developed in 10 children, including 8 (10.5%) patients after open and 2 (9.1%) – after laparoscopic pyloromyotomy (p=0.842). Perforation of mucosa was in one (4.55%) child during laparoscopic pyloromyotomy, but in case of open approach this complication was absent. Independence of the approach, the cases of incomplete myotomy were absent. The surgical site infection (3.95%), postoperative hernia (2.63%), and adhesive bowel obstruction (2.63%) were more often observed after open pyloromyotomy. Laparoscopic pyloromyotomy characterized by the decrease of terms of starting enteral feeding (p<0.001) and length of hospital stay (p=0.031) compared with open pyloromyotomy. Conclusions. Pyloromyotomy remains the main method of treatment of newborns with pyloric stenosis, but a type of approach was chosen by surgeon. Open and laparoscopic pyloromyotomy equally effective and safe for the treatment of children with the hypertrophic pyloric stenosis. The research was carried out in accordance with the principles of the Helsinki declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: hypertrophic pyloric stenosis, newborns, treatment, pyloromyotomy, laparoscopy.

Zenker's diverticulum: advancing beyond the tunnel.

Background and AimsZenker’s diverticulum (ZD) is attributed to a poorly compliant cricopharyngeus muscle, and the mainstay of treatment is a cricopharyngeal myotomy. We present a video series summarizing endoscopic treatment options for ZD and related conditions.MethodsWe review the rationale and key technique for various endoscopic treatment modalities for ZD, cricopharyngeal bar, and other esophageal diverticula.ResultsStandard flexible endoscopic cricopharyngeal myotomy involves the division of the common wall or septum of the ZD, aiming for complete transection of the cricopharyngeus. However, recurrence rates are high, likely owing to incomplete myotomy. Zenker’s peroral endoscopic myotomy (Z-POEM) uses a proximal submucosal tunnel to provide direct visualization of the cricopharyngeus and septum, allowing confirmation of complete myotomy. We demonstrate an over-the-septum modification to simplify the technique. Submucosal fibrosis, commonly seen in patients with prior treatment, limits submucosal dissection. We present a hybrid technique to overcome this, whereby a traditional septotomy is performed until submucosal tissue is visualized. The intact mucosal flap after Z-POEM in a large ZD may contribute to residual dysphagia. We propose Z-POEM with mucosotomy for large ZD. Finally, we demonstrate modifications for treatment of other esophageal diseases, including cricopharyngeal bar and non-Zenker’s esophageal diverticula.ConclusionEndoscopic treatment options for ZD and related conditions are rapidly expanding. With careful tailoring to individual patient characteristics, our expanding arsenal of options allows effective and safe treatment of a broad spectrum of patients.

Retrograde Myotomy as an Alternative to Antegrade Myotomy in Peroral Endoscopic Myotomy (POEM) for Achalasia Cardia - Is It Better?

Antegrade approach myotomy is usually performed in peroral endoscopic myotomy (POEM) for achalasia cardia. This study assessed the feasibility of retrograde approach as an alternative. This is a retrospective review of a prospectively maintained database of patients undergoing POEM, comparing the 2 techniques of antegrade myotomy (AM) and retrograde myotomy (RM). AM was performed by the conventional technique of proximal to distal myotomy while RM was from the distal end to proximal. The time required for myotomy, complications, and technical nuances were compared. Of the 24 cases of POEM, 6 were done by RM and 18 by AM approach. The baseline characteristics, symptomatology, type of achalasia, and preprocedure Eckardt score were similar between the 2 technique arms. The median myotomy time for AM was 21 minute while for RM was 25 minute (P=0.07). Complication rates were similar.Technical issues during RM included: (1) difficulty in visualizing the depth of myotomy; (2) incomplete myotomy requiring back and forth scope adjustment; (3) need for antegrade movement for completion of myotomy; (4) difficulty visualizing the axis of myotomy; (5) added arm strain during posterior myotomy. Our study did not find any additional benefit of RM compared with AM approach for POEM.

S1343 EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty

INTRODUCTION: Gastroparesis (Gp) patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation is an effective treatment strategy in these patients. We aimed to: 1) Assess if pyloric Through the Scope (TTS) balloon dilation results in symptom improvement in Gp patients with suboptimal response to pyloromyotomy/pyloroplasty; 2) Determine Endoscopic Functional Luminal Imaging Probe (EndoFLIP) characteristics of these patients before dilation. METHODS: Patients with severe Gp refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation to 18, 19 and 20 mm after assessing the pyloric characteristics at 30-, 40-, and 50-ml EndoFLIP distension volumes. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS: Thirteen (10 females) patients (mean age 45.2 ± 5.1 years) with Gp and prior pyloric surgeries (laparoscopic pyloroplasty = 6, endoscopic pyloromyotomy = 5, laparoscopic pyloromyotomy = 1) presented with severe Gp symptoms (mean GCSI total score 3.4 ± 0.3, Table 1). TTS dilation was performed after assessing pyloric characteristics on EndoFLIP. Overall, there was improvement of symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, P = 0.04, Table 2; mean CPGAS score 1.6 ± 0.5, P < 0.01, Table 3), with 5 patients (38%) reporting symptom improvement (4 moderately better; 1 somewhat better), and 8 with little (n = 1) or no (n = 7) improvement. Patients with symptom improvement reported symptoms of nausea (3), vomiting (1), and loss of appetite (1) improving the most. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml (4.7 ± 0.8 vs 13.2 ± 2.9 mm2/mmHg, P = 0.04), 40 ml (7.2 ± 1.0 vs 13.9 ± 2.1 mm2/mmHg, P = 0.02) and 50 ml (4.9 ± 1.0 vs 10.2 ± 1.9 mm2/mmHg, P = 0.04) than patients with little/no improvement. CONCLUSION: In Gp patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility suggesting incomplete myotomy, pyloric muscle regeneration or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with Gp symptoms refractory to pyloromyotomy/pyloroplasty.Table 1Table 2Table 3

Does laparoscopic reoperation yield symptomatic improvements similar to those of primary laparoscopic Heller myotomy in achalasia patients?

Laparoscopic Heller myotomy fails in approximately 3.5% to 15% of patients. Evidence of successful laparoscopic reoperation is limited to a few studies. This case-control study was conducted in patients who underwent laparoscopic Heller myotomy reoperation (LHM-R) from 2008 to 2016. The operative outcomes, preoperative and last follow-up manometric parameters, and symptom questionnaire results, including the Eckardt, Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and eating assessment tool (EAT-10) scores, were obtained. The data were compared with those of patients who underwent primary laparoscopic Heller myotomy (LHM-1). Thirty-five patients who underwent LHM-R and 35 patients who underwent LHM-1 were included. The reasons for failure in the LHM-R patient group included incomplete myotomy (71.4%), myotomy fibrosis (25.7%) and structural alterations in fundoplication (2.9%). The follow-up duration was 34months for the LHM-R group and 24months for the LHM-1 group (p = 0.557). The procedure was performed by laparoscopy in 100% of the patients in the two groups. No differences were found regarding surgical morbidity (11.4% LHM-R vs. 2.9% LHM-1, p = 0.164). The symptomatic outcomes were equivalent between groups (Eckardt p = 0.063, EAT-10 p = 0.166, GERD-HRQL p = 0.075). An IRP < 15mmHg was achieved in 100% of the LHM-R and LHM-1 patients. At the last follow-up, 82.1% of the LHM-R patients and 91.4% of the LHM-1 patients were in symptomatic remission (p = 0.271). The results achieved with LHM-R are similar to those achieved with LHM-1. Laparoscopic reoperation should be considered an effective and safe treatment after a failed Heller myotomy.

EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty

Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. Thirteen (ten females) patients (mean age 45.2 ± 5.1years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30ml, 40ml, and 50ml than patients with little/no improvement (all p < 0.05). In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.

Feasibility of using an led-probe in third-space endoscopy: a clinical study

BackgroundThird-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures.MethodsThis prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed.ResultsSeventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38–71) and 60(IQR: 48–77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients.ConclusionsUsing an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

Simple mathematical equation to predict distance to gastroesophageal junction through the submucosal tunnel during peroral endoscopic myotomy.

Background and aim Accurate estimation of the distance to the gastroesophageal junction (GEJ) through a tunnel during per oral endoscopic myotomy (POEM) is technically challenging. The methods currently employed are often insufficient, and resultant errors may lead to incomplete myotomy and/or prolonged procedure times. Our hypothesis states that the additional distance while traversing the tunnel is directly proportional to the widest esophageal diameter; and is calculated by the formula X = Y + CZ (X = distance to the GEJ through the tunnel, Y = distance to the GEJ through the lumen, Z = widest esophageal diameter, C = arithmetic constant). This study evaluates the validity and accuracy of this hypothesis. Patients and methods This was a prospective single-center study with 80 patients, 12 in the pilot group and 68 in the study group. In the pilot group, Y was recorded during esophagogastroduodenoscopy (EGD) before POEM, Z on barium swallow/contrast enhanced computed tomography (CECT), and X was measured during POEM. Using the formula, mean C (SD) was calculated. In the study group, ‘C’ was substituted in the equation to predict the GEJ distance through the tunnel (Xp) before POEM. The operator was blinded to Xp and recorded the true Xt during POEM. The correlation between Xp and Xt was calculated. Results In the pilot group, the mean distances (cm, SD) for X, Y, and Z were 42.58 (3.33), 39.83 (3.08), and 4.39 (1.16), respectively. The calculated mean C was 0.63 (0.11). In the study group, the mean distances (cm, SD) for Y, Z, Xp, and Xt were 40.45 (2.58), 4.99 (1.43), 43.57 (2.68), and 43.54 (2.78), respectively. The Xp and Xt values demonstrated a high correlation (r = 0.97, P = 0.000). Conclusions Formula X = Y + CZ reliably predicts the GEJ distance through a tunnel during POEM. It is user friendly and requires no additional resources.

423 Blown out Myotomy (BOM), a Complication Following Laparoscopic Heller Myotomy and Per-Oral Endoscopic Myotomy

INTRODUCTION: Achalasia results from a failure of lower esophageal sphincter relaxation and an absence of normal peristalsis. Achalasia is diagnosed by High-Resolution Manometry (HRM) and can be treated with Laparoscopic Heller Myotomy (LHM) or Per-oral Endoscopic Myotomy (POEM). LHM and POEM are highly effective with more than 90% clinical efficacy reported in the literature. Although success rates are encouraging, patients may experience complications and recurrent symptoms. We identified patients, status post LHM or POEM, who had a BOM, a pseudodiverticulum at the prior myotomy site, on follow-up. Our aim was to assess what factors are associated with a BOM and how this affects patient reported outcomes. METHODS: We retrospectively identified patients from the Northwestern Esophageal Center Achalasia Natural History Study undergoing HRM between 1/2015 and 10/2017, following LHM or POEM, as therapy for achalasia. Patients must have also had a post-treatment esophagram within 1 year of HRM. A BOM was defined radiographically as a wide-mouthed outpouching (&gt;50% increase in esophageal diameter) in the area of the prior myotomy (Image). RESULTS: 129 consecutive patients were identified; demographics are in Table 1. A BOM was identified in 17.8% of patients. Comparing patients with a BOM to those without, initial achalasia subtypes were overall different (P = 0.004), type III achalasia specifically was more common (39.1% vs. 14.2%, P = 0.014), and LHM was more common than POEM (73.9% vs. 26.1%, P = 0.013), respectively (Table). Anterior vs. posterior approach for POEM and wrap type (Nissen, Dor, Toupet), when LHM was performed, were not predictors of BOM occurrence. Multiple treatments (prior LHM, POEM or pneumatic dilation) was not associated with an increased risk of BOM formation. The Integrated Relaxation Pressure (IRP) was significantly higher in patients with BOM compared to those without (15.0 mmHg vs. 11.0 mmHg, P = 0.025). Eckardt Scores (ES) were significantly higher, both statistically and clinically, in patients with BOM (5 vs. 2, P = 0.002). CONCLUSION: Our analysis suggests that an esophageal myotomy to treat spastic achalasia, treatment with LHM, and a higher post-treatment IRP are more common in patients with a BOM. These findings suggest that increased wall strain, whether it be from residual spastic contractility, continued outflow obstruction from fundoplication, or an incomplete myotomy, may be the underlying mechanism of failure.

Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia.

Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux. Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux. Median follow-up was 3years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up. This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0-2.5cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.

Revisional Procedures for Recurrent Symptoms After Heller Myotomy and Per-Oral Endoscopic Myotomy.

Background: Achalasia and other esophageal motility disorders are incurable diseases for which palliation and symptom relief are the goals. One of the many ways these diseases are treated is with either a Heller myotomy or, now more commonly, per-oral endoscopic myotomy (POEM). Unfortunately, symptoms persistence or recurrence is common. This review presents our current approach to these complex patients. Methods: Review of the literature pertaining to approaches to recurrent or persistent symptoms after myotomy for esophageal motility disorders and elucidation of our multidisciplinary approach to this patient group. Results: There are a myriad of causes of recurrent or persistent symptoms. These include incomplete myotomy, periesophageal scarring, reflux-induced stricture, obstructing fundoplication, functional dysphagia, and end-stage achalasia. Therapeutic options include redo myotomy (either Heller or POEM), botulinum toxin injection, pneumatic, balloon or Savary dilation, adhesiolysis, and fundoplication reversal or esophagectomy. Choice of approach is best done through multidisciplinary consensus. Conclusions: A multidisciplinary approach to patients with persistent and recurrent symptoms after myotomy can best tailor the therapeutic approach based on symptom causation.

Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy

BackgroundRecurrent/persistent symptoms of achalasia occur in 10–20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. MethodsAll patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. Data collected: demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. ResultsA total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. ConclusionThere are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.

Modified Bianchi pyloromyotomy versus laparoscopic pyloromyotomy for patients with infantile hypertrophic pyloric stenosis: Intraoperative considerations and parents satisfaction

Introduction Infantile hypertrophic pyloric stenosis is a common cause of persistent nonbilious vomiting during infancy. Ramstedt pyloromyotomy through right upper quadrant transverse incision is the conventional treatment. The laparoscopic and Tan-Bianchi approaches were introduced to improve the cosmesis and decrease postoperative morbidity. In this study, we compared between laparoscopic and modified Bianchi approaches regarding intraoperative technical considerations and postoperative outcomes.Patients and methods The study included 40 patients with infantile hypertrophic pyloric stenosis. Overall, 20 patients underwent laparoscopic pyloromyotomy (LP) and the other 20 patients underwent modified Bianchi pyloromyotomy (MBP). Patients’ characteristics, including age, sex, gestational age, and associated comorbidities, were documented. Intraoperative details and complications and postoperative outcomes were recorded.Results The operative time and intraoperative complications including mucosal perforation and bleeding did not significantly differ between both the groups. From the laparoscopic group, one (5%) case was complicated by mucosal perforation and converted to open and another case (5%) developed hypercapnia. There was no statistically significant difference between the two groups regarding time till full feed (P=0.648) and postoperative hospital stay (P=0.082). In addition, there was no statistically significant difference between the two groups regarding postoperative complications, with one (5%) case from the laparoscopic group underwent incomplete myotomy and required redo-operation and another case (5%) developed wound infection. MBP had a significantly more parent satisfaction regarding cosmesis than LP (P=0.016).Conclusion MBP is comparable to LP regarding intraoperative complications and postoperative outcomes; however, the modified Bianchi approach offered more parent satisfaction than laparoscopic approach. Keywords: laparoscopic, modified Bianchi, pyloric stenosis, pyloromyotomy