Laparoscopic Endoscopic Myotomy of Esophageal Achalasia (EA)

 

Introduction

Esophageal achalasia (EA) is a neuromuscular disorder of unknown etiology that affects esophageal motility and lower esophageal sphincter function. As a result, the passage of food and fluid into the stomach disrupts, which can lead to expansion of the lumen of the esophagus with food and fluid retention in its lumen. The classic triad of the disease is dysphagia, regurgitation, and pain.

For a long time, balloon dilatation of the cardia, laparoscopic Heller surgery, actively uses now, remained the “classic” method of treating patients with AP. Each of these methods is not without drawbacks, characterizes by a certain frequency of complications, and relapses.

During their internship in laparoscopic technique, many of them have not received practical training with simulators Laparoscopic Trainer.

The change in the principles of treating patients with AP towards more aggressive approaches began in 2008.  Performed the first oral endoscopic myotomy (POEM), and in 2010 published the first results of this intervention.

At present, the high efficiency of POEM in the treatment of patients with AP, including those with stage IV of the disease according to the classification of B.V., has convincingly proven in pediatric patients. Many studies have conducts comparing the effectiveness of this intervention with cardiodilatation, the Heller operation, demonstrating the advantages of POEM, including efficiency and safety.

At the same time, publications contain indications of complications of both the operation itself and those arising in the postoperative period easily correct using endoscopic technologies. The aim of the study was to evaluate the results of oral endoscopic myotomy in patients with AP in one medical institution.

Material and Methods

For the period 2017-2020 in the department of thoracic surgery the clinic, POEM with AP was performed in 50 patients aged 15 to 72 years (mean age 49.6 ± 12.9 years), of which 20 were men and 30 women. The duration of the disease ranged from 6 months to 40 years (mean value 6.7±5.0 years)

The diagnosis of AP establish based on complaints, anamnesis data, the results of fluoroscopy of the esophagus and stomach with barium suspension. The distribution of patients depending on complaints presented in Table. 1, distribution by sex and stage of the disease according to B.V. - in the table.

X-ray data of the esophagus and stomach with barium suspension: the lumen of the esophagus expands throughout; there is a delay in the passage of barium suspension into the stomach.

Before POEM, 18 patients underwent endoscopic treatment of achalasia: balloon dilatation of the cardia performs in 17 cases (eight had one course, two had two, four had three, and three had four or more courses). One patient underwent laparoscopic Heller surgery. When assessed scale before surgery, the spread ranged from 10 to 12 points, (mean score 11.12±0.75 points).

All interventions perform in the operating room under general anesthesia with tracheal intubation. Interventions perform with Olympus endoscopes with a distal cap and using a CO2 insufflator UCRO Olympus. After examining the lumen of the esophagus and determining the cardia at a distance of 10-12 cm above the cardia, along the back (n = 10) or right side wall (n=40) a 0.9% sodium chloride solution tinted with indigo carmine was injected into the submucosal layer.

Then, using a mucosal incision 1.5–2 cm long makes and penetrates into the submucosal layer. After that, a tunnel form, which ended 2.5–4 cm below the esophago gastric junction (43–45 cm from the incisors) in the spray coagulation mode. After that, retreating 2–2.5 cm below the mucotomy (31–35 cm from the incisors), using the circular muscular layer of the esophagus dissect with the transition to the cardia and stomach.

When carrying out the apparatus into the stomach after dissection, the latter passed freely. Then clipping of the mucosal defect perform, through which the device pass into the submucosal layer using endoscopic clips.

Result

Fluoroscopy of the esophagus and stomach perform with a water-soluble contrast agent to assess the patency of the esophageal-gastric junction, after which the patient allow to take fluids. From the 2nd day of the postoperative period, patients began to take liquid and semi-liquid food. Patients discharge from the hospital on the 3rd-4th day after the operation.

X-ray data of the esophagus and stomach with a water-soluble contrast agent (1st day after surgery): the contrast agent passes freely into the stomach, there are no contrast agent “streaks”, endoscopic clips are determined.

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