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Alexander S. Rosemurgy - One of the best experts on this subject based on the ideXlab platform.
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Robotic Heller Myotomy
Robotic-Assisted Minimally Invasive Surgery, 2018Co-Authors: Sharona B. Ross, Darrell Downs, Iswanto Sucandy, Alexander S. RosemurgyAbstract:Achalasia is a rare esophageal dysmotility disorder of unknown etiology that affects approximately 1 in 100,000 people. It is characterized by haphazard contractility or absent peristalsis of the esophagus and uncoordinated relaxation of a hypertensive lower esophageal sphincter (LES) mechanism. The combination of esophageal dysmotility and uncoordinated LES relaxation produces the debilitating symptoms of achalasia, i.e., symptoms of esophageal outlet obstruction (e.g., dysphagia with liquids and solids and regurgitation, aspiration), as well as other symptoms associated with esophageal spasm, like chest pain. Treatment for achalasia has evolved considerably over the past 30 years. From thoracotomies and celiotomies to endoscopic techniques (e.g., pneumatic balloon dilations and botulinum toxin injections and, most recently, POEM) to minimally invasive surgical techniques (e.g., laparoscopic Myotomy, to laparo-endoscopic single-site [LESS] Myotomy, to robotic Myotomy). Today, Heller Myotomy is considered the “gold standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. We have undertaken Heller Myotomy on over 700 patients. Herein, we outline our surgical technique for robotic Heller Myotomy, which is based upon this experience.
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Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.
American Surgeon, 2018Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Luberice K, Patel K, Paul Toomey, Christian Rodriguez, Forat Swaid, Sharona B. RossAbstract:This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller Myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller Myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller Myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller Myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller Myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller Myotomy with anterior fundoplication.
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Dissatisfaction after Laparoscopic Heller Myotomy: The Truth is Easy to Swallow
American Journal of Surgery, 2017Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Carrie E. Ryan, Gianvanna Jadick, Kenneth Luberice, Forat Swaid, Sharona B. RossAbstract:Abstract Background Although laparoscopic Heller Myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are “Dissatisfied”. This study was undertaken to identify the causes of their dissatisfaction. Study design Patients undergoing laparoscopic Heller Myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from “Very Satisfying” to “Very Unsatisfying.” Results 647 patients underwent laparoscopic Heller Myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m 2 reported dissatisfaction at follow-up subsequent to Myotomy. “Dissatisfied” patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). “Dissatisfied” patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after Myotomy for dissatisfied patients (p > 0.05). Conclusion Dissatisfaction after laparoscopic Heller Myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.
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Reoperative Heller Myotomy: more pain, less gain.
American Surgeon, 2015Co-Authors: Thomas W. Wood, Carrie E. Ryan, Ty A. Bowman, Benjamin L. Jacobi, Michael G. Konstantinidis, Sharona B. Ross, Alexander S. RosemurgyAbstract:Heller Myotomy provides durable and effective treatment of achalasia. Due to recurrence or persistence of symptoms, a small subset of patients seeks reoperation. This study was undertaken to determine if reoperative Heller Myotomy provides salutary amelioration of symptoms. 609 patients undergoing laparoscopic Heller Myotomy between 1992 to 2013 were prospectively followed; 38 underwent reoperative Myotomy. Patients graded their symptom frequency and severity before and after Myotomy on a Likert scale. Median data are reported. Patients undergoing reoperative Myotomy, when compared to those undergoing their first Myotomy, experienced a higher conversion rate to an "open" Myotomy (8% vs 1%, P < 0.05) and a longer length of stay (3 vs 1 day, P < 0.05). Reoperative Myotomy led to improvement in symptoms, but the magnitude of improvement in symptoms (e.g., dysphagia, choking, and coughing) was less than for patients undergoing their first Myotomy (all P < 0.05). Patients undergoing reoperative Heller Myotomy were less likely to report symptoms occurring once per month or less (83% vs 56%, P < 0.01). Patients undergoing reoperative Myotomy note improvement in symptoms, although to a lesser extent than patients undergoing their first Myotomy. Patients undergoing reoperative Heller Myotomy can expect to experience less improvement of symptoms, denoting the importance of the first Myotomy.
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laparoendoscopic single site heller Myotomy with anterior fundoplication for achalasia
Surgical Endoscopy and Other Interventional Techniques, 2011Co-Authors: Linda K Barry, Connor Morton, Chinyere Okpaleke, Melissa Rosas, Sujat Dahal, Sharona B. Ross, Alexander S. RosemurgyAbstract:Background Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller Myotomy with anterior fundoplication. However, the efficacy of LESS Heller Myotomy has not been established. This study aimed to evaluate the authors’ initial experience with LESS Heller Myotomy for achalasia.
Sharona B. Ross - One of the best experts on this subject based on the ideXlab platform.
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Robotic Heller Myotomy
Robotic-Assisted Minimally Invasive Surgery, 2018Co-Authors: Sharona B. Ross, Darrell Downs, Iswanto Sucandy, Alexander S. RosemurgyAbstract:Achalasia is a rare esophageal dysmotility disorder of unknown etiology that affects approximately 1 in 100,000 people. It is characterized by haphazard contractility or absent peristalsis of the esophagus and uncoordinated relaxation of a hypertensive lower esophageal sphincter (LES) mechanism. The combination of esophageal dysmotility and uncoordinated LES relaxation produces the debilitating symptoms of achalasia, i.e., symptoms of esophageal outlet obstruction (e.g., dysphagia with liquids and solids and regurgitation, aspiration), as well as other symptoms associated with esophageal spasm, like chest pain. Treatment for achalasia has evolved considerably over the past 30 years. From thoracotomies and celiotomies to endoscopic techniques (e.g., pneumatic balloon dilations and botulinum toxin injections and, most recently, POEM) to minimally invasive surgical techniques (e.g., laparoscopic Myotomy, to laparo-endoscopic single-site [LESS] Myotomy, to robotic Myotomy). Today, Heller Myotomy is considered the “gold standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. We have undertaken Heller Myotomy on over 700 patients. Herein, we outline our surgical technique for robotic Heller Myotomy, which is based upon this experience.
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Laparoscopic Heller Myotomy with Anterior Fundoplication Improves Frequency and Severity of Symptoms of Achalasia, Regardless of Preoperative Severity Determined by Esophagography.
American Surgeon, 2018Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Luberice K, Patel K, Paul Toomey, Christian Rodriguez, Forat Swaid, Sharona B. RossAbstract:This study was undertaken to determine whether postoperative outcomes after laparoscopic Heller Myotomy with anterior fundoplication could be predicted by preoperative findings on esophagography. Preoperative barium esophagograms of 135 patients undergoing laparoscopic Heller Myotomy with anterior fundoplication were reviewed. The number of esophageal curves, esophageal width, and angulation of the gastroesophageal junction (GEJ) were determined; correlations between these determined parameters and symptoms were assessed using linear regression analysis. The number of esophageal curves correlated with the preoperative frequency of dysphagia, vomiting, chest pain, regurgitation, and heartburn. The width of the esophagus negatively correlated with the preoperative frequency of regurgitation. The angulation of the GEJ did not correlate with preoperative symptoms. Laparoscopic Heller Myotomy with anterior fundoplication significantly reduced the frequency and severity of all symptoms, regardless of the number of esophageal curves, esophageal width, or angulation of the GEJ. Laparoscopic Heller Myotomy with anterior fundoplication provides dramatic palliation for achalasia. More esophageal curves on preoperative esophagography correlate well with the frequency of a broad range of preoperative symptoms, including the frequency of dysphagia and regurgitation. Patients experience dramatically improved frequency and severity of symptoms after laparoscopic Heller Myotomy with anterior fundoplication for achalasia regardless of the number of esophageal curves, esophageal width, or the angulation of the GEJ. Findings on barium esophagogram, in evaluating achalasia, should not deter the application of laparosocopic Heller Myotomy with anterior fundoplication.
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Dissatisfaction after Laparoscopic Heller Myotomy: The Truth is Easy to Swallow
American Journal of Surgery, 2017Co-Authors: Alexander S. Rosemurgy, Darrell Downs, Carrie E. Ryan, Gianvanna Jadick, Kenneth Luberice, Forat Swaid, Sharona B. RossAbstract:Abstract Background Although laparoscopic Heller Myotomy has been shown to well palliate symptoms of achalasia, we have observed a small subset of patients who are “Dissatisfied”. This study was undertaken to identify the causes of their dissatisfaction. Study design Patients undergoing laparoscopic Heller Myotomy from 1992 to 2015 were prospectively followed. Using a Likert scale, patients rated their symptom frequency/severity before and after the procedure. Patients graded their experience from “Very Satisfying” to “Very Unsatisfying.” Results 647 patients underwent laparoscopic Heller Myotomy. Fifty (8%) patients, median age 57 years and BMI 24 kg/m 2 reported dissatisfaction at follow-up subsequent to Myotomy. “Dissatisfied” patients were more likely to have undergone prior abdominal operations (p = 0.01) or previous myotomies (p = 0.02). “Dissatisfied” patients had a greater incidence of diverticulectomy (p = 0.03) and had longer postoperative LOS (p = 0.01). Symptom frequency/severity persisted after Myotomy for dissatisfied patients (p > 0.05). Conclusion Dissatisfaction after laparoscopic Heller Myotomy is directly related to persistent/recurrent symptoms. Previous abdominal operations/myotomies, diverticulectomies, and longer LOS are predictors of dissatisfaction. With this understanding, we can identify patients who might be more prone to dissatisfaction.
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Reoperative Heller Myotomy: more pain, less gain.
American Surgeon, 2015Co-Authors: Thomas W. Wood, Carrie E. Ryan, Ty A. Bowman, Benjamin L. Jacobi, Michael G. Konstantinidis, Sharona B. Ross, Alexander S. RosemurgyAbstract:Heller Myotomy provides durable and effective treatment of achalasia. Due to recurrence or persistence of symptoms, a small subset of patients seeks reoperation. This study was undertaken to determine if reoperative Heller Myotomy provides salutary amelioration of symptoms. 609 patients undergoing laparoscopic Heller Myotomy between 1992 to 2013 were prospectively followed; 38 underwent reoperative Myotomy. Patients graded their symptom frequency and severity before and after Myotomy on a Likert scale. Median data are reported. Patients undergoing reoperative Myotomy, when compared to those undergoing their first Myotomy, experienced a higher conversion rate to an "open" Myotomy (8% vs 1%, P < 0.05) and a longer length of stay (3 vs 1 day, P < 0.05). Reoperative Myotomy led to improvement in symptoms, but the magnitude of improvement in symptoms (e.g., dysphagia, choking, and coughing) was less than for patients undergoing their first Myotomy (all P < 0.05). Patients undergoing reoperative Heller Myotomy were less likely to report symptoms occurring once per month or less (83% vs 56%, P < 0.01). Patients undergoing reoperative Myotomy note improvement in symptoms, although to a lesser extent than patients undergoing their first Myotomy. Patients undergoing reoperative Heller Myotomy can expect to experience less improvement of symptoms, denoting the importance of the first Myotomy.
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laparoendoscopic single site heller Myotomy with anterior fundoplication for achalasia
Surgical Endoscopy and Other Interventional Techniques, 2011Co-Authors: Linda K Barry, Connor Morton, Chinyere Okpaleke, Melissa Rosas, Sujat Dahal, Sharona B. Ross, Alexander S. RosemurgyAbstract:Background Laparoendoscopic single-site (LESS) surgery is beginning to include advanced laparoscopic operations such as Heller Myotomy with anterior fundoplication. However, the efficacy of LESS Heller Myotomy has not been established. This study aimed to evaluate the authors’ initial experience with LESS Heller Myotomy for achalasia.
Shin-ei Kudo - One of the best experts on this subject based on the ideXlab platform.
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per oral endoscopic Myotomy a series of 500 patients
Journal of The American College of Surgeons, 2015Co-Authors: Haruhiro Inoue, Hitomi Minami, Manabu Onimaru, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Kevin L Grimes, Hiroshi Yokomichi, Yasutoshi Kobayashi, Shin-ei KudoAbstract:Background After the first case of per-oral endoscopic Myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical Myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution. Study Design Per-oral endoscopic Myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, Myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up. Results Per-oral endoscopic Myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p Conclusions Per-oral endoscopic Myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.
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greater curvature Myotomy is a safe and effective modified technique in per oral endoscopic Myotomy with videos
Gastrointestinal Endoscopy, 2015Co-Authors: Manabu Onimaru, Haruhiro Inoue, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Chainarong Phalanusitthepha, Esperanza Grace Santi, Kevin L Grimes, Hiroaki Ito, Shin-ei KudoAbstract:Background Per-oral endoscopic Myotomy (POEM) for achalasia with esophagocardioMyotomy in the lesser curvature (LC Myotomy) is now established and accepted widely. However, in some cases LC Myotomy is precluded by previous procedures, such as Heller Myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric Myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. Objective To evaluate esophagocardioMyotomy in the greater curvature (GC Myotomy) as an alternative POEM technique in cases where a prior LC Myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. Design Prospective. Setting Single-center study. Patients Twenty-one achalasia patients who received POEM with GC Myotomy. Interventions POEM. Main Outcome Measurements Efficacy and safety of GC Myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. Results Identification of the EGJ was achieved in all cases, resulting in a mean gastric Myotomy length of 2.6 ± 1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2 ± 7.3 vs 10.5 ± 2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) ( P Limitations Single center. Conclusions GC Myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller Myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.
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Peroral Endoscopic Myotomy Is a Viable Option for Failed Surgical EsophagocardioMyotomy Instead of Redo Surgical Heller Myotomy: A Single Center Prospective Study
Journal of the American College of Surgeons, 2013Co-Authors: Manabu Onimaru, Haruhiro Inoue, Haruo Ikeda, Hiroki Sato, Akira Yoshida, Esperanza Grace Santi, Hiroaki Ito, Roberta Maselli, Shin-ei KudoAbstract:Background Surgical Heller Myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical Myotomy failure is controversial. Recently, peroral endscopic Myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical Myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. Study Design A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical Myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical Myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. Results The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p Conclusions Short-term results of POEM for failed surgical Myotomy were excellent. Long-term results are awaited.
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Peroral Endoscopic Myotomy for Esophageal Achalasia
Video Journal and Encyclopedia of GI Endoscopy, 2013Co-Authors: Haruhiro Inoue, Hitomi Minami, Manabu Onimaru, Haruo Ikeda, Hiroki Sato, Akira Yoshida, Shin-ei KudoAbstract:Abstract Recent advances in endoscopic technology allow us to perform totally endoscopic Myotomy for esophageal achalasia. A submucosal tunnel is first created at the anterior wall of the esophagus down to the gastric cardia. Endoscopic Myotomy is carried out in the submucosal tunnel and then completed at the end of the submucosal tunnel. After confirmation of smooth passage of the endoscope through esophago-gastric junction, the mucosal incision is closed using regular hemostatic clips. In 280 consecutive cases of esophageal achalasia peroral endoscopic Myotomy was used, except in one case, which received laparoscopic Heller Myotomy. Clinical results were excellent, with no significant complication. This article is part of an expert video encyclopedia.
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peroral endoscopic Myotomy for esophageal achalasia technique indication and outcomes
Thoracic Surgery Clinics, 2011Co-Authors: Haruhiro Inoue, Hitomi Minami, Manabu Onimaru, Haruo Ikeda, Akira Yoshida, Kris Ma Tianle, Toshihisa Hosoya, Shin-ei KudoAbstract:Peroral endoscopic Myotomy (POEM) has been developed as an incisionless, minimally invasive endoscopic treatment intending a permanent cure for esophageal achalasia. The concept of endoscopic Myotomy was first reported about 3 decades ago, but the direct incision method through the mucosal layer was not considered to be a safe and reliable approach. A novel method of endoscopic Myotomy was developed and established by the authors. In this article, the current techniques, applications, and clinical results of POEM are described.
André Duranceau - One of the best experts on this subject based on the ideXlab platform.
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sleeve recording of upper esophageal sphincter resting pressures during cricopharyngeal Myotomy
Annals of Surgery, 1997Co-Authors: Manuel Pera, Akira Yamada, Clement A. Hiebert, André DuranceauAbstract:Objective The manometric effects of a 6-cm cricopharyngeal Myotomy are recorded while the operation is being performed from cervical esophagus to the cricopharyngeus and then to the hypopharynx. Background Data Cricopharyngeal Myotomy is used in the treatment of oropharyngeal dysphagia of different causes. The operation decreases the resting pressure in the upper esophageal sphincter (UES). The components responsible for this decrease have not been clarified. Methods Fourteen patients with oropharyngeal dysphagia underwent a sleeve recording of the UES resting pressures under general anesthesia before and after sequential Myotomy of the pharyngoesophageal junction. Patients were assessed in the awake state before and after the whole Myotomy. Results Upper esophageal pressures remain unchanged after division of 2 cm of the cervical esophageal muscle. Section of 2 cm of the cricopharyngeal area results in a significant decrease of the sphincter resting pressure (p < 0.01). The division of 2 cm of hypopharyngeal muscle results in a further significant reduction of the resting pressure (p < 0.005). Conclusions Extension of the cricopharyngeal Myotomy over hypopharyngeal musculature produces a more significant decrease of UES resting pressure.
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Sleeve recording of upper esophageal sphincter resting pressures during cricopharyngeal Myotomy.
Annals of surgery, 1997Co-Authors: Manuel Pera, Akira Yamada, Clement A. Hiebert, André DuranceauAbstract:The manometric effects of a 6-cm cricopharyngeal Myotomy are recorded while the operation is being performed from cervical esophagus to the cricopharyngeus and then to the hypopharynx. Cricopharyngeal Myotomy is used in the treatment of oropharyngeal dysphagia of different causes. The operation decreases the resting pressure in the upper esophageal sphincter (UES). The components responsible for this decrease have not been clarified. Fourteen patients with oropharyngeal dysphagia underwent a sleeve recording of the UES resting pressures under general anesthesia before and after sequential Myotomy of the pharyngoesophageal junction. Patients were assessed in the awake state before and after the whole Myotomy. Upper esophageal pressures remain unchanged after division of 2 cm of the cervical esophageal muscle. Section of 2 cm of the cricopharyngeal area results in a significant decrease of the sphincter resting pressure (p < 0.01). The division of 2 cm of hypopharyngeal muscle results in a further significant reduction of the resting pressure (p < 0.005). Extension of the cricopharyngeal Myotomy over hypopharyngeal musculature produces a more significant decrease of UES resting pressure.
Manabu Onimaru - One of the best experts on this subject based on the ideXlab platform.
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double scope per oral endoscopic Myotomy poem a prospective randomized controlled trial
Surgical Endoscopy and Other Interventional Techniques, 2016Co-Authors: Kevin L Grimes, Haruhiro Inoue, Manabu Onimaru, Haruo Ikeda, Amarit Tansawet, Robert Bechara, Shinwa TanakaAbstract:Since its introduction in 2010, per oral endoscopic Myotomy (POEM) has offered an alternative to laparoscopic Heller Myotomy for the treatment of achalasia. A gastric Myotomy length of 3 cm has been recommended; however, it can be difficult to ensure that adequate submucosal dissection has been performed during the procedure. Commonly accepted endoscopic markers of the gastric side can be inaccurate, particularly in patients with prior endoscopic treatments, such as balloon dilation or Botox injection of the lower esophageal sphincter. We hypothesized that the use of a second endoscope would result in a more complete gastric Myotomy. One hundred consecutive achalasia patients were randomized into single- and double-scope POEM groups. In the treatment group, a second endoscope was used to obtain a retroflexed view of the gastric cardia, while the dissecting scope transilluminated from the end of the submucosal tunnel. Prospectively collected data were analyzed, including Myotomy lengths, procedure times, adverse events, and clinical outcomes. POEM was completed with high rates of technical (98–100 %) and clinical success (93–97 %) in both groups, with a low rate of serious adverse events (2 %). The second endoscope resulted in a 17 min increase in procedure time (94 vs. 77 min), Myotomy extension in 34 % of cases, and an increase in the average gastric Myotomy length from 2.6 to 3.2 cm (p = 0.01). A second endoscope is useful for ensuring a complete gastric Myotomy during POEM. With minimal increase in procedure time and no increase in morbidity, it may be particularly useful in cases of sigmoid esophagus or otherwise altered anatomy that makes identification of the gastroesophageal junction difficult.
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per oral endoscopic Myotomy a series of 500 patients
Journal of The American College of Surgeons, 2015Co-Authors: Haruhiro Inoue, Hitomi Minami, Manabu Onimaru, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Kevin L Grimes, Hiroshi Yokomichi, Yasutoshi Kobayashi, Shin-ei KudoAbstract:Background After the first case of per-oral endoscopic Myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical Myotomy and is now established as an excellent treatment option for achalasia. This study aimed to examine the safety and outcomes of POEM at our institution. Study Design Per-oral endoscopic Myotomy was performed on 500 consecutive achalasia patients at our institution between September 2008 and November 2013. A review of prospectively collected data was conducted, including procedure time, Myotomy location and length, adverse events, and patient data with short- (2 months) and long-term (1 and 3 years) follow-up. Results Per-oral endoscopic Myotomy was successfully completed in all patients, with adverse events observed in 3.2%. Two months post-POEM, significant reductions in symptom scores (Eckardt score 6.0 ± 3.0 vs 1.0 ± 2.0, p Conclusions Per-oral endoscopic Myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy.
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greater curvature Myotomy is a safe and effective modified technique in per oral endoscopic Myotomy with videos
Gastrointestinal Endoscopy, 2015Co-Authors: Manabu Onimaru, Haruhiro Inoue, Haruo Ikeda, Hiroki Sato, Chiaki Sato, Chainarong Phalanusitthepha, Esperanza Grace Santi, Kevin L Grimes, Hiroaki Ito, Shin-ei KudoAbstract:Background Per-oral endoscopic Myotomy (POEM) for achalasia with esophagocardioMyotomy in the lesser curvature (LC Myotomy) is now established and accepted widely. However, in some cases LC Myotomy is precluded by previous procedures, such as Heller Myotomy, or by other anatomic considerations that obscure the normal dissection planes. It may also be difficult to identify the esophagogastric junction (EGJ), which can result in an incomplete gastric Myotomy and poor rates of symptom relief. On the other hand, the angle of His is always located in the greater curvature of the stomach and serves as a consistent, definite landmark of the gastric side. Objective To evaluate esophagocardioMyotomy in the greater curvature (GC Myotomy) as an alternative POEM technique in cases where a prior LC Myotomy or supervening anatomic constraints make identification of the EGJ technically challenging. Design Prospective. Setting Single-center study. Patients Twenty-one achalasia patients who received POEM with GC Myotomy. Interventions POEM. Main Outcome Measurements Efficacy and safety of GC Myotomy measured in terms of reduction in lower esophageal sphincter (LES) pressures, improvement in Eckardt scores, and development of intraoperative or postoperative adverse events. Results Identification of the EGJ was achieved in all cases, resulting in a mean gastric Myotomy length of 2.6 ± 1.1 cm. Mean LES pressure and Eckardt symptom scores decreased significantly (21.2 ± 7.3 vs 10.5 ± 2.7 mm Hg, 5 [2-8] vs 1 [0-5], respectively) ( P Limitations Single center. Conclusions GC Myotomy is a promising, safe modification of the POEM technique and may be especially useful in cases of redo POEM, POEM post-Heller Myotomy, or when the EGJ is difficult to recognize because of supervening anatomic constraints.
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Peroral Endoscopic Myotomy Is a Viable Option for Failed Surgical EsophagocardioMyotomy Instead of Redo Surgical Heller Myotomy: A Single Center Prospective Study
Journal of the American College of Surgeons, 2013Co-Authors: Manabu Onimaru, Haruhiro Inoue, Haruo Ikeda, Hiroki Sato, Akira Yoshida, Esperanza Grace Santi, Hiroaki Ito, Roberta Maselli, Shin-ei KudoAbstract:Background Surgical Heller Myotomy has high rates of successful long-term results, but failed cases still remain. Moreover, the treatment strategy in patients with surgical Myotomy failure is controversial. Recently, peroral endscopic Myotomy (POEM) was reported to be efficient and safe in primary treatment of achalasia. In this study, we aimed to evaluate the efficacy and safety of POEM for surgical Myotomy failure as a rescue second-line treatment, and we discuss the treatment options adapted in achalasia recurrence. Study Design A total of 315 consecutive achalasia patients received POEM from September 2008 to December 2012 in our hospital. Eleven (3.5%) patients who had persistent or recurrent achalasia and had received surgical Myotomy as a first-line treatment from other hospitals were included in this study. Patient background, barium swallow studies, esophagogastroduodenoscopy (EGD), manometry, and symptom scores were prospectively evaluated. In principle, all patients in whom surgical Myotomy failed received pneumatic balloon dilatation (PBD) as the first line "rescue" treatment, and only if PBD failed were patients considered for rescue POEM. Results The PBD alone was effective in 1 patient, and in the remaining 10 patients, rescue POEM was performed successfully without complications. Three months after rescue POEM, significant reduction in lower esophageal sphincter (LES) resting pressures (22.1 ± 6.6 mmHg vs 10.9 ± 4.5 mmHg, p Conclusions Short-term results of POEM for failed surgical Myotomy were excellent. Long-term results are awaited.
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Peroral Endoscopic Myotomy for Esophageal Achalasia
Video Journal and Encyclopedia of GI Endoscopy, 2013Co-Authors: Haruhiro Inoue, Hitomi Minami, Manabu Onimaru, Haruo Ikeda, Hiroki Sato, Akira Yoshida, Shin-ei KudoAbstract:Abstract Recent advances in endoscopic technology allow us to perform totally endoscopic Myotomy for esophageal achalasia. A submucosal tunnel is first created at the anterior wall of the esophagus down to the gastric cardia. Endoscopic Myotomy is carried out in the submucosal tunnel and then completed at the end of the submucosal tunnel. After confirmation of smooth passage of the endoscope through esophago-gastric junction, the mucosal incision is closed using regular hemostatic clips. In 280 consecutive cases of esophageal achalasia peroral endoscopic Myotomy was used, except in one case, which received laparoscopic Heller Myotomy. Clinical results were excellent, with no significant complication. This article is part of an expert video encyclopedia.
