Transesophageal Endoscopic Myotomy (Teem) for the Treatment of Achalasia - the United States Human Experience
Ozanan R. Meireles*1,2, Garth R. Jacobsen1, Toshio Katagiri1, Kari Thompson1, Abraham Mathew4,1, Noam Belkind1, Michael Sedrak1, Bryan J. Sandler1, Takayuki Dotai1, Thomas J. Savides3, Saniea F. Majid1, Sheetal Nijhawan1, Mark a. Talamini1, Santiago Horgan1
1Department of Surgery, University of California San Diego, San Diego, CA; 2Department of Surgery, Massachusetts General Hospital - Harvard Medical School, Boston, MA; 3Department of Gastroenterology, University of California San Diego, San Diego, CA; 4Department of Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA
From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic trans-esophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility and efficacy of TEEM in a series of patients with achalasia. Methods: Under IRB approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, age between 18 and 50 years old, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical co-morbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 O’clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastro-esophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm bellow the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Four patients underwent TEEM, with no peri-operative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first post-op day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach and absence of leaks. All patients were discharged on the second post-op day on liquid diet. Two patients reported transient heartburn, which was well controlled with medications. The average pre-op GERD-HRQL was 20, which improved to 11.3 at 7 days post-op and 2 at 30 days post-op. To date, two patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean pre-op LES resting pressure was 33 mmHg and residual pressure was 41.35 mmHg, whereas the 6-months follow-up mean LES resting pressure was 10.85 mmHg and residual pressure was -0.8 mmHg). Conclusion: TEEM seems to be safe, feasible and effective for the treatment of patients with achalasia. Long-term data is still necessary for wide-spread utilization of this novel technique.
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