Proximal Myotomy Research Articles

Use of a report card to evaluate outcomes of achalasia surgery: beyond the Eckardt score.

Achalasia outcome is primarily defined using the Eckardt score with failure recognized as > 3. However, patients experience many changes after myotomy including new onset GERD, swallowing difficulties, and potential need for additional treatment. We aim to devise a comprehensive assessment tool to demonstrate the extent of patient-reported outcomes, objective changes, and need for re-interventions following myotomy. We performed a retrospective chart review of surgically treated primary achalasia patients. We identified 185 patients without prior foregut surgery who underwent either per oral endoscopic myotomy (POEM) or Heller myotomy from 2005 to 2017. Eight outcome measures in subjective, objective, and interventional categories formulated a global postoperative assessment tool. These outcomes included Eckardt score, Dakkak Dysphagia score, GERD-HRQL score, normalization of pH scores and IRP, esophagitis, timed barium clearance at 5min, and the most invasive re-intervention performed. Of 185 patients, achalasia subtypes included Type I = 42 (23%), II = 109 (59%), and III = 34 (18%). Patients underwent minimally invasive myotomy in 114 (62%), POEM in 71 (38%). Median proximal myotomy length was 4cm (IQR 4-5) and distal 2cm (IQR 2-2.5). Based on postoperative Eckardt score, 135/145 (93%) had successful treatment of achalasia. But, only 47/104 (45%) reported normal swallowing, and 78/108 (72%) had GERD-HRQL score ≤ 10. Objectively, IRP was normalized in 48/60 (80%), whereas timed barium clearance occurred in 51/84 (61%). No evidence of esophagitis was documented in 82/115 (71%). Postoperative normal DeMeester scores occurred in 38/76 (50%). No additional treatments were required in 110/139 (79%) of patients. Use of the Eckardt score alone to assess outcomes after achalasia surgery shows outstanding results. Using patient-reported outcomes, objective measurements, re-intervention rates, organized into a report card provides a more comprehensive and informative view.

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

Bilateral Thoracodorsal Neuromas: A Cause of Persistent Breast Pain after Bilateral Latissimus Dorsi Breast Reconstruction.

An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM.

For laparoscopic Heller myotomy (LHM), the optimal myotomy length proximal to the esophagogastric junction (EGJ) is unknown. In this study, we used a functional lumen imaging probe (FLIP) to measure EGJ distensibility changes resulting from variable proximal myotomy lengths during LHM and peroral esophageal myotomy (POEM). Distensibility index (DI) (defined as the minimum cross-sectional area at the EGJ divided by pressure) was measured with FLIP after each operative step. During LHM and POEM, each patient's myotomy was performed in two stages: first, a myotomy ablating only the EGJ complex was created (EGJ-M), extending from 2 cm proximal to the EGJ, to 3 cm distal to it. Next, the myotomy was lengthened 4 cm further cephalad to create an extended proximal myotomy (EP-M). Measurements were performed in 12 patients undergoing LHM and 19 undergoing POEM. LHM resulted in an overall increase in DI (1.6 ± 1 vs. 6.3 ± 3.4 mm(2)/mmHg, p < 0.001). Creation of an EGJ-M resulted in a small increase (1.6-2.3 mm(2)/mmHg, p < 0.01) and extension to an EP-M resulted in a larger increase (2.3-4.9 mm(2)/mmHg, p < 0.001). This effect was consistent, with 11 (92%) patients experiencing a larger increase after EP-M than after EGJ-M. Fundoplication resulted in a decrease in DI and deinsufflation an increase. POEM resulted in an increase in DI (1.3 ± 1 vs. 9.2 ± 3.9 mm(2)/mmHg, p < 0.001). Both creation of the submucosal tunnel and performing an EGJ-M increased DI, whereas lengthening of the myotomy to an EP-M had no additional effect. POEM resulted in a larger overall increase from baseline than LHM (7.9 ± 3.5 vs. 4.7 ± 3.3 mm(2)/mmHg, p < 0.05). During LHM, an EP-M was necessary to normalize distensibility, whereas during POEM, a myotomy confined to the EGJ complex was sufficient. In this cohort, POEM resulted in a larger overall increase in EGJ distensibility.

Effect of level of circular myotomy on oesophageal function in a piglet model

Oesophageal continuity is often difficult to obtain in “long-gap” oesophageal atresia, and a circular myotomy may be required to achieve oesophageal anastomosis. This study compared the effects of upper and lower segmental circular myotomy on oesophageal stricture formation, oesophageal motility, and the development of gastro-oesophageal reflux (GOR) in a piglet model. Group I underwent mid-oesophageal resection with upper segment myotomy (14); group II mid-oesophageal resection with lower segment myotomy (8); and group III oesophageal transection and anastomosis without resection (6). Normal motility data were obtained from 8 unmanipulated piglets. The incidence of stricture formation was high in all operated groups. Pseudodiverticula developed in all piglets after proximal myotomy, but not after transection or distal myotomy. Lower oesophageal sphincter pressure and mean amplitude of upper oesophageal contractions were similar after operation in all groups and in controls. GOR (number of reflux episodes/24 h, number of episodes of reflux lasting more than 5 min, and fraction of time pH less than 4.0) was worse after operation compared to controls. Within each group most manometric parameters and GOR worsened with time. We found no evidence that the level of circular myotomy (upper or lower) resulted in any significant difference in stricture rate, oesophageal motility, or severity of GOR. Given the difficulty of performing an upper myotomy in long-gap atresia, where the upper segment is often very short and pseudodiverticulum formation is common, a lower-segment circular myotomy would appear to be a reasonable alternative.

Circular Esophageal Myotomy in the Rhesus Monkey: Anatomical and Physiological Effects

Thirty-one rhesus monkeys were divided into six groups: a control group of 4 monkeys in which resection of 33% of the thoracic esophagus with end-to-end anastomosis was performed with-out myotomy, and test groups of 4 to 6 monkeys each in which circular myotomy in the proximal segment, distal segment, or both was combined with a 25% or 33% resection. In the control group, 2 of 4 monkeys survived. In the test groups, myotomy reduced longitudinal tension by 20 to 58%. Among the survivors were 4 of 6 animals that had 25% resection with proximal myotomy, 3 of 5 having 25% resection with distal myotomy, and 3 of 4 having 25% resection with combined proximal and distal myotomy. However, 4 of 5 monkeys that had 33% resection plus proximal myotomy and all 5 having 33% resection plus distal myotomy died of anastomotic leaks or strictures. Cineesophagography in surviving monkeys showed no motility disturbance at the myotomy sites. Manometry in 5 monkeys showed no change in resting lower esophageal sphincter pressure from that measured preoperatively. Postmortem examination in long-term survivors showed no stricture or dilatation at the myotomy sites. It is concluded that circular myotomy in the rhesus monkey reduces longitudinal tension, but compromise of the esophageal blood supply limits the usefulness of the procedure in bridging long gaps in the esophagus. Myotomy did not result in any motility disturbance or late anatomical sequelae, and therefore is still a valid procedure to facilitate the repair of short defects.