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Endoscopic myotomy in the treatment of achalasia
0016-5107/80/2601-0006$02.00/0 GASTROINTESTINAL ENDOSCOPY
Copyright © 1980 by the American Society for Gastrointestinal Endoscopy
Endoscopic myotomy in the treatment of achalasia J. A. Ortega, MD V. Madureri, MD L. Perez, MD Caracas, Venezuela
Seventeen patients with achalasia were treated by endoscopic myotomy limited to the esophageal rosette and avoiding the distal antireflux zone. Clinical, radiological, endoscopic, and manometric follow-up revealed improvement comparable to that seen in patients after successful surgical myotomy or pneumatic dilation. In the hands of the authors, the procedure has been simple, fast, effective, and safe, thus providing an alternative treatment of achalasia.
There is still controversy about the treatment of achalasia. Some prefer pneumatic dilation,I-2 while others use surgery to lower or abolish distal esophageal obstruction. 3 -4 Insofar as alterations in the esophageal rosette when observed endoscopically after successful surgical or pneumatic treatment are closely correlated, it seems logical that myotomy, limited to the functional obstruction and corresponding with the esophageal rosette, would produce satisfactory results. We report the results obtained following endoscopically guided incision, with an electrosurgical knife, at the area of functional obstruction while carefully avoiding the distal antireflux zone. MATERIALS AND METHODS The electrosurgical knife (Figure 1) was developed by us and can be easily introduced through the biopsy channel of an endoscope. It was made from a steel wire 1 mm in diameter with its distal tip sharpened and slightly angled. The proximal part end was connected to an electrosurgical unit. The wire with its active pole slides through a Teflon catheter that serves as insulation and also permits precise control of protrusion and, hence, the depth of the cut. The myotomy procedure was performed first on dogs and later on human patients. Six mongrel dogs, weighing 20 to 25 kg and anesthetized with pentothal, were endoscoped. After identification of the esophagogastric junction, 2 incisions 1 cm long were made above the "I" line so as to cut circular fibers of the esophagus without perforating the wall. To obtain this depth, the incisions were performed with varying wire protrusions and different current intensities. The dogs were then sacrificed, and the esophagus evaluated. An optimal incision was obtained with a wire protrusion of 3 mm and a blended current of 25 Bovie units. Seventeen patients with the clinical, radiologic, manometric, and endoscopic diagnosis of achalasia were then
submitted to the myotomy procedure. Thirty minutes previously meperidine 100 mg and atropine 0.5 mg were given intramuscularly; diazepam 10 mg was slowly given intravenously. The throat was anesthetized with Xylocaine spray. With the patient in the left lateral decubitus position an endoscope was passed into the stomach. After introducing the knife, the endoscope was slowly withdrawn under visual control. The lunula, "I" line, and the segment with functional stenosis were carefully evaluated. Incisions were then made under direct endoscopic control at the distal end of the rosette. Patients were given nothing by mouth for 24 hours; later, food was given as tolerated. Radiographic, manometric, and endoscopic observations were made periodically. Esophageal manometry was performed with the constant perfusion, open-tip catheter technique integrated with a Hewlett-Packard 7692 inscription system. Endoscopies were performed with conventional fiberoptic instruments. Radiographs with the patient in the left lateral decubitus position with the esophagus fully distended with barium.
RESULIS When myotomy was performed in dogs, all incisions were limited from the mucosa to the circular fibers (Figure 2), and in no case was there perforation. Bleeding was seen to occur if the cut extended below the "I" line and was easily controlled by electrocoagulation. All of our human patients, following myotomy, had reduction in tone of the rosette which appeared open and irregularly shaped (Figure 3). Three patients bled during the procedure, and this was immediately controlled by electrocoagulation. All patients improved symptomatically. Deglutition was easier, solid foods passed readily, and there was no regurgitation or fullness. Weight gains averaged 5 kg. Postmyotomy follow-up ranged from 3 to 25 months. Two patients complained of minimal dysphagia although it was considerably less than before treatment. Fluoroscopic and radiographic follow-up showed easy
From the Gastroenterology Service of the General Hospital "lIdemaro Salas" of the Social Security Institute, San Martin-Caracas, Venezuela.
8
GASTROINTESTINAL ENDOSCOPY
•. 5
•. 0
'.5
LO
0.5
Figure 1. The endoscopically guided electrosurgical knife. BEFORE
2.15~,.OZmm
AFTER
IZ.e:!::s.'",,"
Figure 4. Maximum diameters of the distal esophageal lumen before and after endoscopic myotomy in 17 patients with achalasia (P
< 0.05).
Figure 2. Transverse sections of dog esophaguses showing the limited depth of incision by the endoscopically guided electro;urgical knife
Figure 3. A, In the right inferior quadrant is seen the point of the bistoury (the slender electrosurgical knife). Band C, Incisions are shown in both inferior quadrants. D, The rosette is opened and irregular.
passage of barium with a wide gastroesophageal junction and a less distended esophagus. The maximal diameter of the distal esophagus increased from 2.7 to 12.6 mm after treatment (Figures 4 and 5). VOLUME 26, NO. 1, 1980
Figure 5. Radiographs of the barium-filled esophagus in 2 patients with achalasia before (left) and after (right) endoscopic myotomy. A, 21 months after myotomy; B, 12 months after myotomy.
9
BEFORE
Figure 6. Manometric tracings taken from the high pressure zone before and after endoscopic myotomy.
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Figure 7. Manometric pressures recorded at the distal high pressure zones of 17 patients with achalasia before and after endoscopic myotomy (P < 0.01).
Manometry after treatment showed a definitive decline in the pressure of the obstructed area (Figure 6). Mean expiratory pressure dropped from a pretreatment level of 34.5 ± 11.2 mm Hg to a post-treatment level of 9.2 ± 3.8 mm Hg (Figure 7). These results are statistically significant (P < 0.(01). Endoscopic follow-up showed a permanently open esophageal rosette with easy endoscopic passage. 10
DISCUSSION In achalasia there is no known method to modify the peristaltic alterations inherent in the disease. Therefore, treatment has been directed to alleviating the distal high pressure zone so as to permit esophageal emptying by gravity. Heretofore, surgical myotomy or pneumatic dilation were the only methods of accomplishing this. Both methods have been reported to entail significant complications. The degree of dilation necessary to obtain an adequate rupture of the circular fibers is difficult to estimate so improvement may be temporary; hemorrage and perforation are constant risks. 7 Complications of surgical myotomy include vagal section or alteration of structure in the esophagogastric area. s The Heller procedure can result in reflux in as many as 52% of patients. 9 When surgical myotomy extends beyond the cardioesophageal junction, peptic esophagitis has been reported in 4.4% of cases. 10 Myotomy limited above the lower esophageal sphincter brings about a noncontractile segment of esophagus similar to a diverticulum and even a sliding hiatal hernia. The use of the endoscopically guided electrosurgical knife can be safely employed in the distal esophagus if the depth of cut is controlled. This can be obtained with the instrument designed by us when it is appropriately used. The technique of endoscopic myotomy has the following advantages: (1) it is simple and easy, (2) it incises only on the obstructed area and avoids the antiflux zone, (3) it is a true esophageal myotomy insofar as the section of circular fibers is performed above the esophagogastric union, (4) forceful dilation or thoracotomy is avoided, and (5) only moderate sedation and not general anesthesia is required. This technique must be performed by an adequately trained endoscopist with a precise knowledge of the anatomic area and the physiologic result desired.
1. VAN GOIDSENHOVER GE, VANTRAPPEN G, VERBEKE S, VANDENBROUCKE J: Treatment of achalasia of the cardia with pneumatic dilatations. Gastroenterology 45:326, 1%3 2. KURLANDER DF, RASKIN HF, KIRSNER JB, PALMER WL: Therapeutic value of pneumatic dilator in achalasia of the esophagus. 45: 604,1%3 3. ELLIs FH, OLSEN AM, HOLMAN CB, CODE CF: Surgical treatment of cardiospasm (achalasia of the esophagus). lAMA 166:29, 1958 4. EFFLER DB, Loop FD, GROVES LK, FAVAROLO RG: Primary surgical treatment for esophageal achalasia. Surg Gynecol Obstet 132: 1057, 1971 5. VANTRAPPEN G, VAN GOIDSENHOVEN GE, VERBEKE S, BERGHE G, VANDENBROUCKE J: Manometric studies in achalasia of the cardia before and after pneumatic dilatations. Gastroenterology 45:317, 1%3 6. OLSEN AM, SCHLEGEl jF, CREAMER B, ELLIs FH jR: Esophageal motility in achalasia after treatment. I Thorac Surg 34:615,1957 7. VANTRAPPEN G, HELLEMANS J, DELOOf W, VALEMBOIS, P, VANDENBROUCKE J: Treatment of achalasia with pneumatic dilatations. Gut 12:268, 1971 8. ELLIs FH, jR, GIBB SP: Reoperation after esophagomyotomy for achalasia of the esophagus. Am I Surg 129:407, 1975 9, HAWTHORNE HR, FROBESE AS, NEMIR P jR: The surgical management of achalasia of the esophagus. Ann Surg 144:653, 1956 10. ELLIs FH jR, KISER!C, SCHLEGEl jF, EARLAM RJ, MCVERY jL, OLSEN AM: Esophagomyotomy of esophageal achalasia: experimental, clinical and manometric aspects. Ann Surg 166:640, 1967 GASTROINTESTINAL ENDOSCOPY
Copyright © 1980 by the American Society for Gastrointestinal Endoscopy
Endoscopic myotomy in the treatment of achalasia J. A. Ortega, MD V. Madureri, MD L. Perez, MD Caracas, Venezuela
Seventeen patients with achalasia were treated by endoscopic myotomy limited to the esophageal rosette and avoiding the distal antireflux zone. Clinical, radiological, endoscopic, and manometric follow-up revealed improvement comparable to that seen in patients after successful surgical myotomy or pneumatic dilation. In the hands of the authors, the procedure has been simple, fast, effective, and safe, thus providing an alternative treatment of achalasia.
There is still controversy about the treatment of achalasia. Some prefer pneumatic dilation,I-2 while others use surgery to lower or abolish distal esophageal obstruction. 3 -4 Insofar as alterations in the esophageal rosette when observed endoscopically after successful surgical or pneumatic treatment are closely correlated, it seems logical that myotomy, limited to the functional obstruction and corresponding with the esophageal rosette, would produce satisfactory results. We report the results obtained following endoscopically guided incision, with an electrosurgical knife, at the area of functional obstruction while carefully avoiding the distal antireflux zone. MATERIALS AND METHODS The electrosurgical knife (Figure 1) was developed by us and can be easily introduced through the biopsy channel of an endoscope. It was made from a steel wire 1 mm in diameter with its distal tip sharpened and slightly angled. The proximal part end was connected to an electrosurgical unit. The wire with its active pole slides through a Teflon catheter that serves as insulation and also permits precise control of protrusion and, hence, the depth of the cut. The myotomy procedure was performed first on dogs and later on human patients. Six mongrel dogs, weighing 20 to 25 kg and anesthetized with pentothal, were endoscoped. After identification of the esophagogastric junction, 2 incisions 1 cm long were made above the "I" line so as to cut circular fibers of the esophagus without perforating the wall. To obtain this depth, the incisions were performed with varying wire protrusions and different current intensities. The dogs were then sacrificed, and the esophagus evaluated. An optimal incision was obtained with a wire protrusion of 3 mm and a blended current of 25 Bovie units. Seventeen patients with the clinical, radiologic, manometric, and endoscopic diagnosis of achalasia were then
submitted to the myotomy procedure. Thirty minutes previously meperidine 100 mg and atropine 0.5 mg were given intramuscularly; diazepam 10 mg was slowly given intravenously. The throat was anesthetized with Xylocaine spray. With the patient in the left lateral decubitus position an endoscope was passed into the stomach. After introducing the knife, the endoscope was slowly withdrawn under visual control. The lunula, "I" line, and the segment with functional stenosis were carefully evaluated. Incisions were then made under direct endoscopic control at the distal end of the rosette. Patients were given nothing by mouth for 24 hours; later, food was given as tolerated. Radiographic, manometric, and endoscopic observations were made periodically. Esophageal manometry was performed with the constant perfusion, open-tip catheter technique integrated with a Hewlett-Packard 7692 inscription system. Endoscopies were performed with conventional fiberoptic instruments. Radiographs with the patient in the left lateral decubitus position with the esophagus fully distended with barium.
RESULIS When myotomy was performed in dogs, all incisions were limited from the mucosa to the circular fibers (Figure 2), and in no case was there perforation. Bleeding was seen to occur if the cut extended below the "I" line and was easily controlled by electrocoagulation. All of our human patients, following myotomy, had reduction in tone of the rosette which appeared open and irregularly shaped (Figure 3). Three patients bled during the procedure, and this was immediately controlled by electrocoagulation. All patients improved symptomatically. Deglutition was easier, solid foods passed readily, and there was no regurgitation or fullness. Weight gains averaged 5 kg. Postmyotomy follow-up ranged from 3 to 25 months. Two patients complained of minimal dysphagia although it was considerably less than before treatment. Fluoroscopic and radiographic follow-up showed easy
From the Gastroenterology Service of the General Hospital "lIdemaro Salas" of the Social Security Institute, San Martin-Caracas, Venezuela.
8
GASTROINTESTINAL ENDOSCOPY
•. 5
•. 0
'.5
LO
0.5
Figure 1. The endoscopically guided electrosurgical knife. BEFORE
2.15~,.OZmm
AFTER
IZ.e:!::s.'",,"
Figure 4. Maximum diameters of the distal esophageal lumen before and after endoscopic myotomy in 17 patients with achalasia (P
< 0.05).
Figure 2. Transverse sections of dog esophaguses showing the limited depth of incision by the endoscopically guided electro;urgical knife
Figure 3. A, In the right inferior quadrant is seen the point of the bistoury (the slender electrosurgical knife). Band C, Incisions are shown in both inferior quadrants. D, The rosette is opened and irregular.
passage of barium with a wide gastroesophageal junction and a less distended esophagus. The maximal diameter of the distal esophagus increased from 2.7 to 12.6 mm after treatment (Figures 4 and 5). VOLUME 26, NO. 1, 1980
Figure 5. Radiographs of the barium-filled esophagus in 2 patients with achalasia before (left) and after (right) endoscopic myotomy. A, 21 months after myotomy; B, 12 months after myotomy.
9
BEFORE
Figure 6. Manometric tracings taken from the high pressure zone before and after endoscopic myotomy.
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70
• I
eo
:t
!•
eo
f= ~
~ •f
40
III
eo
)(
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REFERENCES .0
10
Figure 7. Manometric pressures recorded at the distal high pressure zones of 17 patients with achalasia before and after endoscopic myotomy (P < 0.01).
Manometry after treatment showed a definitive decline in the pressure of the obstructed area (Figure 6). Mean expiratory pressure dropped from a pretreatment level of 34.5 ± 11.2 mm Hg to a post-treatment level of 9.2 ± 3.8 mm Hg (Figure 7). These results are statistically significant (P < 0.(01). Endoscopic follow-up showed a permanently open esophageal rosette with easy endoscopic passage. 10
DISCUSSION In achalasia there is no known method to modify the peristaltic alterations inherent in the disease. Therefore, treatment has been directed to alleviating the distal high pressure zone so as to permit esophageal emptying by gravity. Heretofore, surgical myotomy or pneumatic dilation were the only methods of accomplishing this. Both methods have been reported to entail significant complications. The degree of dilation necessary to obtain an adequate rupture of the circular fibers is difficult to estimate so improvement may be temporary; hemorrage and perforation are constant risks. 7 Complications of surgical myotomy include vagal section or alteration of structure in the esophagogastric area. s The Heller procedure can result in reflux in as many as 52% of patients. 9 When surgical myotomy extends beyond the cardioesophageal junction, peptic esophagitis has been reported in 4.4% of cases. 10 Myotomy limited above the lower esophageal sphincter brings about a noncontractile segment of esophagus similar to a diverticulum and even a sliding hiatal hernia. The use of the endoscopically guided electrosurgical knife can be safely employed in the distal esophagus if the depth of cut is controlled. This can be obtained with the instrument designed by us when it is appropriately used. The technique of endoscopic myotomy has the following advantages: (1) it is simple and easy, (2) it incises only on the obstructed area and avoids the antiflux zone, (3) it is a true esophageal myotomy insofar as the section of circular fibers is performed above the esophagogastric union, (4) forceful dilation or thoracotomy is avoided, and (5) only moderate sedation and not general anesthesia is required. This technique must be performed by an adequately trained endoscopist with a precise knowledge of the anatomic area and the physiologic result desired.
1. VAN GOIDSENHOVER GE, VANTRAPPEN G, VERBEKE S, VANDENBROUCKE J: Treatment of achalasia of the cardia with pneumatic dilatations. Gastroenterology 45:326, 1%3 2. KURLANDER DF, RASKIN HF, KIRSNER JB, PALMER WL: Therapeutic value of pneumatic dilator in achalasia of the esophagus. 45: 604,1%3 3. ELLIs FH, OLSEN AM, HOLMAN CB, CODE CF: Surgical treatment of cardiospasm (achalasia of the esophagus). lAMA 166:29, 1958 4. EFFLER DB, Loop FD, GROVES LK, FAVAROLO RG: Primary surgical treatment for esophageal achalasia. Surg Gynecol Obstet 132: 1057, 1971 5. VANTRAPPEN G, VAN GOIDSENHOVEN GE, VERBEKE S, BERGHE G, VANDENBROUCKE J: Manometric studies in achalasia of the cardia before and after pneumatic dilatations. Gastroenterology 45:317, 1%3 6. OLSEN AM, SCHLEGEl jF, CREAMER B, ELLIs FH jR: Esophageal motility in achalasia after treatment. I Thorac Surg 34:615,1957 7. VANTRAPPEN G, HELLEMANS J, DELOOf W, VALEMBOIS, P, VANDENBROUCKE J: Treatment of achalasia with pneumatic dilatations. Gut 12:268, 1971 8. ELLIs FH, jR, GIBB SP: Reoperation after esophagomyotomy for achalasia of the esophagus. Am I Surg 129:407, 1975 9, HAWTHORNE HR, FROBESE AS, NEMIR P jR: The surgical management of achalasia of the esophagus. Ann Surg 144:653, 1956 10. ELLIs FH jR, KISER!C, SCHLEGEl jF, EARLAM RJ, MCVERY jL, OLSEN AM: Esophagomyotomy of esophageal achalasia: experimental, clinical and manometric aspects. Ann Surg 166:640, 1967 GASTROINTESTINAL ENDOSCOPY