Transcervical heller myotomy using flexible endoscopy.
BACKGROUND
Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach.


METHODS
This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates.


RESULTS
Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061).


CONCLUSIONS
Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.
Spaun
Georg O
GO
Minimally Invasive Surgery Program, Legacy Health, 1040 NW 22nd Ave, Suite 560, Portland, OR 97210, USA. georg.spaun@gmail.com
Dunst
Christy M
CM
Arnold
Brittany N
BN
Martinec
Danny V
DV
Cassera
Maria A
MA
Swanström
Lee L
LL
D000818:Animals; D002299:Cardia / Q000601:surgery; D004867:Equipment Design; D004931:Esophageal Achalasia / Q000601:surgery*; D020701:Esophagoscopes; D004945:Esophagoscopy / Q000379:methods*; D005240:Feasibility Studies; D009333:Neck; D013552:Swine