Department of Gastrointestinal and Endocrine Surgery, IRCAD-EITS, University of Strasbourg, Strasbourg, France.
Surg Endosc. 2010 Nov;24(11):2903. doi: 10.1007/s00464-010-1073-3. Epub 2010 Apr 29.
It is generally accepted that the most effective treatment of achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 30% of patients. The aim of this study was to explore a transoral incisionless stepwise approach to both esophageal Heller myotomy and fundoplication.
The first step consisted of creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the esophagogastric junction (EGJ). The mucosa on the right posterolateral esophageal wall was cut with the needle-knife 15 cm above the lower esophageal sphincter (LES) and then dilated with blunt dissection to introduce the scope. A submucosal tunnel was created distally with CO(2) and blunt dissection. Once the gastroesophageal junction (GEJ) and the clasp fibers were identified, the muscular layer was cut. The scope was withdrawn into the lumen and the mucosal flap was sealed with endoscopic clips. The adequacy of the myotomy was evaluated using pre- and postoperative manometry and by comparing the EGJ distensibility before, during, and after the division of the esophageal muscular fibers using the functional lumen imaging probe, EndoFLIP®. The second step, consisted of building a transoral incisionless fundoplication 4 weeks postoperatively using the EsophyX™.
Both Heller myotomy and endoscopic fundoplication were accomplished successfully with no injury to the esophageal mucosa. Postoperative manometry demonstrated a 50% loss in mean LES pressure (mean preoperative LES pressure = 22.2 mmHg; mean postoperative LES pressure = 10 mmHg, P < 0.005). The EndoFLIP® showed a preoperative minimal diameter of 6 mm with a cross-sectional area of 28 mm(2). Postoperatively, the junction was more compliant (minimal diameter = 15 mm; cross-sectional area = 177 mm(2)), with the main improvement in distensibility occurring when the clasps fibers were removed.
A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible and effective in the porcine model. A distensibility test such as the EndoFLIP® may provide better information on the opening and closing dynamics of the EGJ, rather than just relying on the sphincter tonic state as measured by manometry.
人们普遍认为贲门失弛缓症的最有效治疗方法是手术肌切开术。然而，如果仅进行肌切开术，多达 30%的患者可能会出现反流。本研究旨在探讨经口无切口逐步食管 Heller 肌切开术和胃底折叠术的方法。
第一步包括创建食管肌切开术。在全身麻醉下，将猪仰卧位，进行内镜检查以评估食管胃交界处（EGJ）的位置。在食管下括约肌（LES）上方 15cm 处用针刀切开食管右后外侧的粘膜，然后用钝性解剖法扩张引入内镜。用 CO2 和钝性解剖法在远端创建黏膜下隧道。一旦识别出胃食管交界处（GEJ）和扣带纤维，就可以切开肌肉层。将内镜撤回至管腔，并使用内镜夹密封粘膜瓣。使用术前和术后测压法以及通过使用功能性内腔成像探头（EndoFLIP®）在食管肌肉纤维分割之前、期间和之后比较 EGJ 可扩张性来评估肌切开术的充分性。第二步，在术后 4 周使用 EsophyX™进行经口无切口胃底折叠术。
食管 Heller 肌切开术和内镜胃底折叠术均成功完成，无食管粘膜损伤。术后测压显示平均 LES 压力降低 50%（术前平均 LES 压力=22.2mmHg；术后平均 LES 压力=10mmHg，P<0.005）。EndoFLIP®显示术前最小直径为 6mm，横截面积为 28mm²。术后，交界处的顺应性更好（最小直径=15mm；横截面积=177mm²），主要改善发生在去除扣带纤维时。
经口无切口逐步食管 Heller 肌切开术和部分胃底折叠术在猪模型中是可行且有效的。与仅依靠测压法测量的括约肌紧张度相比，EndoFLIP®等扩张试验可以提供更好的 EGJ 开口和关闭动力学信息。
