TY - JOUR
T1 - An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM
AU - Teitelbaum, Ezra N.
AU - Soper, Nathaniel J.
AU - Pandolfino, John E.
AU - Kahrilas, Peter J.
AU - Boris, Lubomyr
AU - Nicodème, Frédéric
AU - Lin, Zhiyue
AU - Hungness, Eric S.
N1 - Publisher Copyright:
© 2014, Springer Science+Business Media New York.
PY - 2014/10
Y1 - 2014/10
N2 - Background: 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).Methods: 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).Results: 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 mm2/mmHg, p < 0.001). Creation of an EGJ-M resulted in a small increase (1.6–2.3 mm2/mmHg, p < 0.01) and extension to an EP-M resulted in a larger increase (2.3–4.9 mm2/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 mm2/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 mm2/mmHg, p < 0.05).Conclusions: 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.
AB - Background: 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).Methods: 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).Results: 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 mm2/mmHg, p < 0.001). Creation of an EGJ-M resulted in a small increase (1.6–2.3 mm2/mmHg, p < 0.01) and extension to an EP-M resulted in a larger increase (2.3–4.9 mm2/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 mm2/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 mm2/mmHg, p < 0.05).Conclusions: 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.
KW - Achalasia
KW - Esophageal physiology
KW - Functional lumen imaging probe
KW - Laparoscopic Heller myotomy
KW - Peroral endoscopic myotomy
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U2 - 10.1007/s00464-014-3563-1
DO - 10.1007/s00464-014-3563-1
M3 - Article
C2 - 24853854
AN - SCOPUS:84939889815
SN - 0930-2794
VL - 28
SP - 2840
EP - 2847
JO - Surgical endoscopy
JF - Surgical endoscopy
IS - 10
ER -