Transcervical Heller Myotomy Using Flexible Endoscopy
- First Online:
- 70 Downloads
Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach.
This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates.
Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061).
Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.
KeywordsNOTES Flexible endoscopy Achalasia Heller myotomy Mediastinoscopy
- 5.Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P. Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures. Endoscopy 2007;39(10):870–5.CrossRefPubMedGoogle Scholar
- 8.Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ. Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos). Gastrointest Endosc 2008;67(3):497–501.CrossRefPubMedGoogle Scholar
- 14.Kipfmuller K, Duda D, Kessler S, Melzer A, Buess G. [Endoscopic microsurgical dissection of the esophagus: a contribution to the reduction of pulmonary complications following esophageal resection? A comparative animal experiment study]. Langenbecks Arch Chir 1990;375(1):11–8.CrossRefPubMedGoogle Scholar
- 15.Buess G, Becker HD (1990) Minimally invasive surgery in tumors of the esophagus. Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir 1990:1355–60.Google Scholar
- 19.Spaun GO, Zheng B, Martinec DV, Cassera MA, Dunst CM, Swanstrom LL. Bimanual coordination in natural orifice transluminal endoscopic surgery: comparing the conventional dual-channel endoscope, the R-Scope, and a novel direct-drive system. Gastrointest Endosc 2009;69(6):e39–45.CrossRefPubMedGoogle Scholar
- 20.Spaun GO, Zheng B, Swanstrom LL. A multitasking platform for natural orifice translumenal endoscopic surgery (NOTES): a benchtop comparison of a new device for flexible endoscopic surgery and a standard dual-channel endoscope. Surg Endosc 2009;23(12):2720–27.Google Scholar
- 21.Heller E. Extramukoese Cardiaplastik beim chronischen Cardiospasmus mit Dilatation des Oesophagus Mittheil. a. d, Grenzgeb. d. Med. u. Chir. 1914(Bd. xxvii):S. 141.Google Scholar
- 22.Fritscher-Ravens A, Cuming T, Jacobsen B, Seehusen F, Ghanbari A, Kahle E, von Herbay A, Koehler P, Milla P. Feasibility and safety of endoscopic full-thickness esophageal wall resection and defect closure: a prospective long-term survival animal study. Gastrointest Endosc 2009;69(7):1314–20.CrossRefPubMedGoogle Scholar