Pescarus Radu, Sharata Ahmed, Shlomovitz Eran, Reavis Kevin, Dunst Christy, Swanstrom Lee
Providence Portland Cancer Center, Portland, OR, USA.
The Oregon Clinic, Portland, OR, USA.
Surg Endosc. 2016 Jul;30(7):3099. doi: 10.1007/s00464-015-4561-7. Epub 2015 Oct 30.
Esophageal obstruction is a known complication of laparoscopic adjustable gastric band (LAGB) and usually occurs in the context of band slippage. Current reports of pseudoachalasia post-LAGB describe that in some patients esophageal function improves after band removal. For those without improvement, current treatments include division of the fibrotic band post-LAGB or revisional surgery. Our hypothesis, illustrated in the submitted video, is that an endoscopic division of LAGB-induced stricture will improve esophageal function.
This video presents the case of a patient presenting with dysphagia post-LAGB removal. The preoperative high-resolution manometry was compatible with a type I achalasia. Using a high-definition endoscope and the equipment used for per-oral endoscopic myotomy (POEM) procedure, the intramural fibrotic tissue caused by the LAGB is divided, thus releasing the stricture and restoring baseline esophageal function. This is demonstrated with intraoperative endoscopic functional lumen imaging probe (EndoFLIP; Crospon Ltd, Galway, Ireland).
Similar to the POEM technique, a 12-cm tunnel and 8-cm myotomy were performed. No intra-procedural or post-procedural complications were noted. Using impedance planimetry, the division of the LAGB-induced stricture induced an increase in the minimal diameter from 5.3 to 8.6 mm. The cross-sectional area increased from 22 to 58 mm(2). The patient denies any residual dysphagia, regurgitation, or heartburn at 6-month follow-up. On the postoperative high-resolution manometry, significant improvement in LES pressure parameters was seen post-myotomy with return of 30 % peristalsis.
In LAGB patients with pseudoachalasia in which removal of fluid from the band does not result in clinical or manometric improvement, laparoscopic removal of the band with division of the peri-esophageal scar tissue has been advocated. This video illustrates that an endoscopic division of the LAGB-induced esophageal fibrosis is another potential treatment for adjustable gastric band-induced achalasia.
食管梗阻是腹腔镜可调节胃束带术（LAGB）的一种已知并发症，通常发生在束带滑脱的情况下。目前关于LAGB术后假性贲门失弛缓症的报道称，一些患者在移除束带后食管功能有所改善。对于那些没有改善的患者，目前的治疗方法包括LAGB术后纤维束带的分离或翻修手术。我们在提交的视频中展示的假设是，内镜下分离LAGB引起的狭窄将改善食管功能。
本视频展示了一例LAGB移除术后出现吞咽困难的患者。术前高分辨率测压结果与I型贲门失弛缓症相符。使用高清内窥镜和用于经口内镜下肌切开术（POEM）的设备，将LAGB引起的壁内纤维组织分离，从而解除狭窄并恢复食管功能基线。术中使用内镜功能腔成像探头（EndoFLIP；爱尔兰戈尔韦的Crosspon有限公司）进行了演示。
与POEM技术类似，进行了12厘米的隧道和8厘米的肌切开术。未观察到术中或术后并发症。使用阻抗平面测量法，分离LAGB引起的狭窄使最小直径从5.3毫米增加到8.6毫米。横截面积从22平方毫米增加到58平方毫米。患者在6个月随访时否认有任何残留的吞咽困难、反流或烧心症状。术后高分辨率测压显示，肌切开术后LES压力参数有显著改善，蠕动恢复了30%。
对于LAGB术后出现假性贲门失弛缓症且从束带中抽出液体后临床或测压无改善的患者，有人主张腹腔镜下移除束带并分离食管周围瘢痕组织。本视频表明，内镜下分离LAGB引起的食管纤维化是可调节胃束带引起的贲门失弛缓症的另一种潜在治疗方法。
