Ezra N Teitelbaum1, Joel M Sternbach2, Rym El Khoury2, Nathaniel J Soper2, John E Pandolfino3, Peter J Kahrilas3, Zhiyue Lin3, Eric S Hungness2. 1. Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron Street, Galter 3-150, Chicago, IL, 60611, USA. e-teitelbaum@northwestern.edu. 2. Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron Street, Galter 3-150, Chicago, IL, 60611, USA. 3. Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Abstract
BACKGROUND: During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. METHODS: EGJ distensibility index (DI) (minimum cross-sectional area divided by intrabag pressure) was measured with FLIP after each operative step. Each patient's myotomy was performed in four increments from proximal to distal: (1) an esophageal myotomy (from 6 cm proximal to the EGJ to 1 cm proximal to it), (2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1 cm proximal to the EGJ to 1 cm distal to it), (3) an initial gastric extension (from 1 cm distal to the EGJ to 2 cm distal), and (4) a final gastric extension (from 2 cm distal to the EGJ to 3 cm distal). RESULTS: Measurements were taken in 16 achalasia patients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm(2)/mmHg, p < .001). Initial creation of the submucosal tunnel resulted in a threefold increase in DI (1.2 vs. 3.6 mm(2)/mmHg, p < .001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2 cm distal to the EGJ). The final gastric myotomy extension (to 3 cm distal) had no further effect. CONCLUSIONS: During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2 cm onto the gastric wall resulted in the normalization of EGJ distensibility, whereas subsequent extension to 3 cm distal to the EGJ did not increase compliance further.
BACKGROUND: During peroral esophageal myotomy (POEM) for the treatment of achalasia, the optimal distal gastric myotomy length is unknown. In this study, we used a functional lumen imaging probe (FLIP) to intraoperatively measure the effect of variable distal myotomy lengths on esophagogastric junction (EGJ) distensibility. METHODS: EGJ distensibility index (DI) (minimum cross-sectional area divided by intrabag pressure) was measured with FLIP after each operative step. Each patient's myotomy was performed in four increments from proximal to distal: (1) an esophageal myotomy (from 6 cm proximal to the EGJ to 1 cm proximal to it), (2) a myotomy ablating the lower esophageal sphincter (LES) complex (from 1 cm proximal to the EGJ to 1 cm distal to it), (3) an initial gastric extension (from 1 cm distal to the EGJ to 2 cm distal), and (4) a final gastric extension (from 2 cm distal to the EGJ to 3 cm distal). RESULTS: Measurements were taken in 16 achalasiapatients during POEM. POEM resulted in an overall increase in DI (pre 1.2 vs. post 7.2 mm(2)/mmHg, p < .001). Initial creation of the submucosal tunnel resulted in a threefold increase in DI (1.2 vs. 3.6 mm(2)/mmHg, p < .001). When the myotomy was then performed in a stepwise fashion from proximal to distal, the initial esophageal myotomy component had no effect on DI. Subsequent myotomy extension across the LES complex resulted in an increase in DI, as did the initial gastric myotomy extension (to 2 cm distal to the EGJ). The final gastric myotomy extension (to 3 cm distal) had no further effect. CONCLUSIONS: During POEM, creation of the submucosal tunnel prior to myotomy resulted in a marked improvement in EGJ physiology. Myotomy extension across the LES complex and to 2 cm onto the gastric wall resulted in the normalization of EGJ distensibility, whereas subsequent extension to 3 cm distal to the EGJ did not increase compliance further.
Authors: Ezra N Teitelbaum; Nathaniel J Soper; John E Pandolfino; Peter J Kahrilas; Lubomyr Boris; Frédéric Nicodème; Zhiyue Lin; Eric S Hungness Journal: Surg Endosc Date: 2014-05-23 Impact factor: 4.584
Authors: H Inoue; H Minami; Y Kobayashi; Y Sato; M Kaga; M Suzuki; H Satodate; N Odaka; H Itoh; S Kudo Journal: Endoscopy Date: 2010-03-30 Impact factor: 10.093
Authors: Ezra N Teitelbaum; Nathaniel J Soper; Byron F Santos; Fahd O Arafat; John E Pandolfino; Peter J Kahrilas; Ikuo Hirano; Eric S Hungness Journal: Surg Endosc Date: 2014-06-18 Impact factor: 4.584
Authors: Anand S Jain; Dustin A Carlson; Joseph Triggs; Michael Tye; Wenjun Kou; Ryan Campagna; Eric Hungness; Donald Kim; Peter J Kahrilas; John E Pandolfino Journal: Am J Gastroenterol Date: 2019-09 Impact factor: 10.864