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Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?

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Abstract

Objective

To report our experience in POEM vs. LHM, with particular focus on myotomy extension.

Background

POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10 to 57%. Myotomy length has been a controversial topic.

Methods

Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10 months (6/32) for POEM and 20 months (6/68) for LHM. All patients with LHM had a myotomy extension ≥3 cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2 cm.

Results

Follow-up was completed in 100% of patients. Efficacy (ES ≤ 3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short-term follow-up (p = 1.000) and 31/35 (88.6%) and 27/35 (77.1%), respectively, in a long-term follow-up (p = 1.000), with average ES drop from 9 to 1.2 (p = 0.0001) in POEM vs. 9.2 to 1.3 (p = 0.0001) in LHM. Major Postoperative complications occurred in 1 patient (leak) for LHM and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1, respectively) (p = 0.0001). Symptomatic reflux cases included 7/35 POEM (20%) vs. 6/35 LHM (17.1%) (p = 0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (4.5%) (p = 1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs. 7/35 LHM (20%) (p = 0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs. 8/35 LHM (22.8%).

Conclusions

A shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow-up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.

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Authors and Affiliations

  1. Esophageal Institute, Hospital Universitario Fundacion Favaloro, Av. Beolgrano 1746, Buenos Aires, Argentina

    Mauricio Ramirez, Cecilia Zubieta, Franco Ciotola, Alfredo Amenabar, Adolfo Badaloni, Fabio Nachman & Alejandro Nieponice

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  1. Mauricio Ramirez
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  2. Cecilia Zubieta
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  3. Franco Ciotola
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  4. Alfredo Amenabar
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  7. Alejandro Nieponice
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Correspondence to Alejandro Nieponice.

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Mauricio Ramirez, Cecilia Zubieta, Franco Ciotola, Alfredo Amenabar, Adolfo Badaloni, Fabio Nachman, and Alejandro Nieponice have no conflict of interest or financial ties to disclose.

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Ramirez, M., Zubieta, C., Ciotola, F. et al. Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?. Surg Endosc 32, 282–288 (2018). https://doi.org/10.1007/s00464-017-5675-x

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  • DOI: https://doi.org/10.1007/s00464-017-5675-x

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