PER-ORAL ENDOSCOPIC MYOTOMY LENGTH BASE ON HIGH RESOLUTION MANOMETRY FINDINGS FOR SPASTIC ESOPHAGEAL MOTILITY DISORDERS
Adham Saad*1, Joel E. Richter2, John W. Jacobs2, Vic Velanovich1
1Surgery, University of South Florida, Tampa, FL; 2Medicine, University of South Florida, Tampa, FL
Background: Per-Oral endoscopic myotomy (POEM) has become an accepted approach for spastic esophageal motility disorders (SEMD). Although standard myotomy lengths for achalasia types I and II are based on extensive experience from Heller myotomy, lengths for other types of spastic disorders have been less well defined. We report our experience with POEM myotomy length based on high resolution manometry (HRM) findings.
Methods: The records of patients who have undergone POEM procedures were reviewed. Each patient underwent evaluation with history, physical examination, timed-barium esophagogram, esophagogastroduodenoscopy, HRM and selectively with endoscopic ultrasound. Each patient received one of the following diagnoses: achalasia types I, II, or III, esophagogastric outflow obstruction (EGOO), Jackhammer esophagus and diffuse esophageal spasm (DES). Each patient was presented at a multidisciplinary esophageal conference of gastroenterologists and surgeons, and treatment was determined by consensus (treatment options included pneumatic dilation, botulium toxin injection, laparoscopic Heller myotomy with fundoplicaiton, POEM and esophagectomy; however, only the POEM patients were included in this study). POEM was done using the anterior myotomy approach. For achalasia type I and II, standard myotomy lengths of at least 6 cm of esophageal circular, with or without longitudinal, muscle and at least 2 cm gastric cardia muscle was done. Length of myotomy for other SEMD, lengths were based on the length of the high pressure zone as measured on the composite HRM view. Patients were grouped into achalasia types I and II, and other SEMD.
Results: 50 patients underwent attempted POEM, with 47 patients completing the procedure. Distribution of SEMD: achalasia I, 6; II, 18; III, 12; EGOO, 4; Jackhammer, 3; DES, 6. One patient had pseudoachalasia due to an esophageal tumor discovered during submucosal tunneling. For type I and II, average esophageal myotomy length was 6.1 + 0.3 cm (range: 6-7 cm) with 2 cm gastric cardia length. For other SEMD, average esophageal myotomy length was 9.6 + 2.6 cm (range: 6-18 cm) with average cardia length 1.7 + 0.7 cm (range: 0-2 cm). There were no complications noted in either group.
Conclusions: SEMD are a heterogenous groups of esophageal motility disorders which require an individualized approach. Although achalasia types I and II can be approached with either laparoscopic Heller myotomy or POEM and achieve identical myotomy lengths, the other SEMD have variable length of esophageal and gastric involvement. For the SEMD with long segments of esophagus involved, HRM is useful for determining the length of the high pressure zone requiring myotomy. In these circumstances, POEM is the preferred method over trans-abdominal or trans-thoracic approaches for achieving adequate myotomy length.
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