- Email: [email protected]
Endoscopic submucosal myotomy for the treatment of achalasia (with video)
Brief Reports 15. Fritscher-Ravens A, Sriram PV, Bobrowski C, et al. Mediastinal lymphadenopathy in patients with or without previous malignancy: EUS-FNAbased differential cytodiagnosis in 153 patients. Am J Gastroenterol 2000;95:2278-84. 16. Song TJ, Lee SS, Park DH, et al. Yield of EUS-guided FNA on the diagnosis of pancreatic/peripancreatic tuberculosis. Gastrointest Endosc 2009;69: 484-91. 17. Puri R, Vilmann P, Sud R, et al. Endoscopic ultrasound-guided fineneedle aspiration cytology in the evaluation of suspected tuberculosis in patients with isolated mediastinal lymphadenopathy. Endoscopy 2010;42:462-7. 18. Song HJ, Park YS, Seo DW, et al. Diagnosis of mediastinal tuberculosis by using EUS-guided needle sampling in a geographic region with an in-
termediate tuberculosis burden. Gastrointest Endosc 2010 Apr 22. [Epub ahead of print]
Digestive Endoscopy Unit (A.L., F.M.L., D.G., A.C., N.U., G.C.), Institute of Pathology (R.R.), Catholic University, Rome, Italy. Request reprints: Alberto Larghi, MD, PhD, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy. Copyright © 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.05.017
Endoscopic submucosal myotomy for the treatment of achalasia (with video) Stavros N. Stavropoulos, MD, Michael D. Harris, MD, Sven Hida, MD, Colin Brathwaite, MD, Christopher Demetriou, MD, James Grendell, MD Mineola, New York, USA
Achalasia is characterized by dysfunction of the myenteric plexus of the esophagus, with loss of inhibitory nerves and unopposed cholinergic stimulation.1 Medical, endoscopic, and surgical treatment modalities have been used with varying success.2 The evolution of an open Heller myotomy to the laparoscopic approach has led many gastroenterologists to consider surgery as the first treatment option. Indeed, the American College of Gastroenterology recommends surgery as the primary therapy in patients with a low surgical risk.3 Other endoscopic approaches have been described. Ortega et al4 performed endoscopic myotomy in 1980. In their study, they used a needle-knife to cut the inner circular muscle fibers of the lower esophageal sphincter (LES) by cutting directly through the mucosa. Despite the impressive results from this albeit small study, the risk of mediastinal contamination from luminal contents by using the mucosal approach is of great concern.5 To our knowledge, this study has not been replicated or reviewed in a larger series. A novel method involving submucosal endoscopy has been used as an entry point for mediastinal access in natural orifice transluminal endoscopic surgery procedures.6 Pascricha et al5 used this technique successfully to perform endoscopic myotomy in a porcine model. A single report in a human patient by using submucosal endoscopy to perform myotomy has recently been reported by Inoue et al.7 We report the first human case of the procedure performed in the United States with the use of this new technique, including short-term follow-up data. www.giejournal.org
CASE REPORT A 44-year-old man with clinical, radiographic, and manometric evidence of achalasia was evaluated at our institution. After obtaining internal review board approval and detailed informed consent, we performed endoscopic myotomy by using a submucosal approach (Video 1, available online at www.giejournal.org). We vigorously removed all food debris from the esophagus and lavaged the upper GI tract with an antibiotic solution (80 mg gentamicin/1000 mL normal saline solution). A submucosal cushion was created from 6 cm proximal to the gastro-
Figure 1. Submucosal tunnel.
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Brief Reports
Figure 2. Lower esophageal sphincter muscle fibers.
Figure 4. Closure of mucosal entry point.
TABLE 1. Manometry findings and dysphagia score premyotomy and postmyotomy Test results
Premyotomy
Postmyotomy
Manometric findings Resting pressure (mm Hg) Residual pressure (mm Hg) Percent relaxation
36 2.5
27 -0.8
77
87
Dysphagia (0-3)
3
0
Regurgitations (0-3)
3
0
Chest pain (0-3)
1
1
Total
7
1
Dysphagia score
Figure 3. Postmyotomy lower esophageal sphincter.
esophageal junction (GEJ) extending to 2 cm distal in the gastric cardia by using an ERBE JET-2 hydrodissector (ERBE, Marrieta, GA, USA). Next, a mucosal nick was created at 6 cm proximal to the GEJ by using a standard needle-knife. We then inserted a dilating balloon (Boston Scientific, Natick, Mass) to dilate the opening and allow passage of the standard gastroscope into the submucosal space. The dilating balloon was then removed, and the submucosal tunnel was intubated (Fig. 1). The endoscope was then advanced to the gastric cardia. The muscle fibers of the LES were easily identified endoscopically (Fig. 2). Myotomy was initiated 2 cm distal to the GEJ and extended through the inner circular muscle fibers of the LES. Myotomy was carried out until the longitudinal muscle fibers were visible (Fig. 3). We then closed the submucosal tunnel with multiple resolution clips at the mucosal entry point (Fig. 4). 1310 GASTROINTESTINAL ENDOSCOPY
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The patient was observed in the hospital and was discharged on postoperative day 2. At 1 month followup, the patient’s modified dysphagia score was 1, down from 7 premyotomy (Table 1). Repeat manometry showed a resting pressure of 27 mm Hg, decreased from 36 mm Hg premyotomy (Table 1). Radiographic improvement was also noted on a timed barium swallow (Fig. 5A and B).
DISCUSSION We report the first human application of endoscopic myotomy in the United States that used the submucosal endoscopy approach. There are multiple advantages of www.giejournal.org
Brief Reports
Figure 5. A, Barium esophagram premyotomy and B, postmyotomy.
this technique. First, the endoscopic approach should theoretically minimize postoperative pain and trochar site infections. Second, by incising only the inner circular muscle fibers, a concomitant antireflux surgery may not be necessary. Because this technique is done from a posterior approach, surgical myotomy could still be performed in the future if recurrence of symptoms were to develop. Further study of this technique is required, including longterm follow-up data. Currently a feasibility study is underway at our institution. DISCLOSURE
2. Richter JE. Update on the management of achalasia: balloons, surgery, and drugs. Expert Rev Gastroenterol Hepatol 2008;2:425-433. 3. Vaezi MF, Richter JE. Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol 1999;94:3406-12. 4. Ortega JA, Madureri V, Pervez L. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc 1980;26:8-10. 5. Pascricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007;39:761-4. 6. Sumiyama K, Gostout CJ, Rajan E, et al. Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc 2007;65:679-83. 7. Inoue H, Minami H, Satodate H, et al. First clinical experience of submucosal endoscopic esophageal myotomy for esophageal achalasia with no skin incision [abstract]. Gastrointest Endosc 2009;69:AB122.
All authors disclosed no financial relationships relevant to this publication. Abbreviations: GEJ, gastroesophageal junction; LES, lower esophageal sphincter.
REFERENCES 1. Nguyen NQ, Holloway RH. Recent developments in esophageal motor disorders. Curr Opin Gastroenterol 2005;21:478-84.
www.giejournal.org
Division of Gastroenterology and Hepatology, Winthrop University Hospital, Mineola, New York, USA. Reprint requests: Stavros N. Stavropoulos, MD, 222 Station Plaza North, Suite 429, Mineola, NY 11501 Copyright © 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.04.016
Volume 72, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY
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termediate tuberculosis burden. Gastrointest Endosc 2010 Apr 22. [Epub ahead of print]
Digestive Endoscopy Unit (A.L., F.M.L., D.G., A.C., N.U., G.C.), Institute of Pathology (R.R.), Catholic University, Rome, Italy. Request reprints: Alberto Larghi, MD, PhD, Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy. Copyright © 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.05.017
Endoscopic submucosal myotomy for the treatment of achalasia (with video) Stavros N. Stavropoulos, MD, Michael D. Harris, MD, Sven Hida, MD, Colin Brathwaite, MD, Christopher Demetriou, MD, James Grendell, MD Mineola, New York, USA
Achalasia is characterized by dysfunction of the myenteric plexus of the esophagus, with loss of inhibitory nerves and unopposed cholinergic stimulation.1 Medical, endoscopic, and surgical treatment modalities have been used with varying success.2 The evolution of an open Heller myotomy to the laparoscopic approach has led many gastroenterologists to consider surgery as the first treatment option. Indeed, the American College of Gastroenterology recommends surgery as the primary therapy in patients with a low surgical risk.3 Other endoscopic approaches have been described. Ortega et al4 performed endoscopic myotomy in 1980. In their study, they used a needle-knife to cut the inner circular muscle fibers of the lower esophageal sphincter (LES) by cutting directly through the mucosa. Despite the impressive results from this albeit small study, the risk of mediastinal contamination from luminal contents by using the mucosal approach is of great concern.5 To our knowledge, this study has not been replicated or reviewed in a larger series. A novel method involving submucosal endoscopy has been used as an entry point for mediastinal access in natural orifice transluminal endoscopic surgery procedures.6 Pascricha et al5 used this technique successfully to perform endoscopic myotomy in a porcine model. A single report in a human patient by using submucosal endoscopy to perform myotomy has recently been reported by Inoue et al.7 We report the first human case of the procedure performed in the United States with the use of this new technique, including short-term follow-up data. www.giejournal.org
CASE REPORT A 44-year-old man with clinical, radiographic, and manometric evidence of achalasia was evaluated at our institution. After obtaining internal review board approval and detailed informed consent, we performed endoscopic myotomy by using a submucosal approach (Video 1, available online at www.giejournal.org). We vigorously removed all food debris from the esophagus and lavaged the upper GI tract with an antibiotic solution (80 mg gentamicin/1000 mL normal saline solution). A submucosal cushion was created from 6 cm proximal to the gastro-
Figure 1. Submucosal tunnel.
Volume 72, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY
1309
Brief Reports
Figure 2. Lower esophageal sphincter muscle fibers.
Figure 4. Closure of mucosal entry point.
TABLE 1. Manometry findings and dysphagia score premyotomy and postmyotomy Test results
Premyotomy
Postmyotomy
Manometric findings Resting pressure (mm Hg) Residual pressure (mm Hg) Percent relaxation
36 2.5
27 -0.8
77
87
Dysphagia (0-3)
3
0
Regurgitations (0-3)
3
0
Chest pain (0-3)
1
1
Total
7
1
Dysphagia score
Figure 3. Postmyotomy lower esophageal sphincter.
esophageal junction (GEJ) extending to 2 cm distal in the gastric cardia by using an ERBE JET-2 hydrodissector (ERBE, Marrieta, GA, USA). Next, a mucosal nick was created at 6 cm proximal to the GEJ by using a standard needle-knife. We then inserted a dilating balloon (Boston Scientific, Natick, Mass) to dilate the opening and allow passage of the standard gastroscope into the submucosal space. The dilating balloon was then removed, and the submucosal tunnel was intubated (Fig. 1). The endoscope was then advanced to the gastric cardia. The muscle fibers of the LES were easily identified endoscopically (Fig. 2). Myotomy was initiated 2 cm distal to the GEJ and extended through the inner circular muscle fibers of the LES. Myotomy was carried out until the longitudinal muscle fibers were visible (Fig. 3). We then closed the submucosal tunnel with multiple resolution clips at the mucosal entry point (Fig. 4). 1310 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 6 : 2010
The patient was observed in the hospital and was discharged on postoperative day 2. At 1 month followup, the patient’s modified dysphagia score was 1, down from 7 premyotomy (Table 1). Repeat manometry showed a resting pressure of 27 mm Hg, decreased from 36 mm Hg premyotomy (Table 1). Radiographic improvement was also noted on a timed barium swallow (Fig. 5A and B).
DISCUSSION We report the first human application of endoscopic myotomy in the United States that used the submucosal endoscopy approach. There are multiple advantages of www.giejournal.org
Brief Reports
Figure 5. A, Barium esophagram premyotomy and B, postmyotomy.
this technique. First, the endoscopic approach should theoretically minimize postoperative pain and trochar site infections. Second, by incising only the inner circular muscle fibers, a concomitant antireflux surgery may not be necessary. Because this technique is done from a posterior approach, surgical myotomy could still be performed in the future if recurrence of symptoms were to develop. Further study of this technique is required, including longterm follow-up data. Currently a feasibility study is underway at our institution. DISCLOSURE
2. Richter JE. Update on the management of achalasia: balloons, surgery, and drugs. Expert Rev Gastroenterol Hepatol 2008;2:425-433. 3. Vaezi MF, Richter JE. Diagnosis and management of achalasia. American College of Gastroenterology Practice Parameter Committee. Am J Gastroenterol 1999;94:3406-12. 4. Ortega JA, Madureri V, Pervez L. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc 1980;26:8-10. 5. Pascricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007;39:761-4. 6. Sumiyama K, Gostout CJ, Rajan E, et al. Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc 2007;65:679-83. 7. Inoue H, Minami H, Satodate H, et al. First clinical experience of submucosal endoscopic esophageal myotomy for esophageal achalasia with no skin incision [abstract]. Gastrointest Endosc 2009;69:AB122.
All authors disclosed no financial relationships relevant to this publication. Abbreviations: GEJ, gastroesophageal junction; LES, lower esophageal sphincter.
REFERENCES 1. Nguyen NQ, Holloway RH. Recent developments in esophageal motor disorders. Curr Opin Gastroenterol 2005;21:478-84.
www.giejournal.org
Division of Gastroenterology and Hepatology, Winthrop University Hospital, Mineola, New York, USA. Reprint requests: Stavros N. Stavropoulos, MD, 222 Station Plaza North, Suite 429, Mineola, NY 11501 Copyright © 2010 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2010.04.016
Volume 72, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY
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