Heller myotomy and intraluminal fundoplication: a NOTES technique
Epublication WebSurg.com, Mar 2010;10(03). URL: http://websurg.com/doi/vd01en2452
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication. Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions). Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred. Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.