150 Hybrid Heller's Myotomy: A Useful Approach When Difficulty Anticipated? A Retrospective Review

Résumé fourni par la source

Abstract Background Laparoscopic myotomy for achalasia is complicated by mucosal perforation in up to 28% of primary procedures and up to 50% of reoperations, with 33% of patients experiencing failure due to inadequate myotomy. We hypothesised that laparoscopic Heller’s myotomy, with endoscopic surveillance of the oesophageal mucosa, via oesophago-gastro-duodenoscopy (OGD), would reduce the incidence of both. This study examined mucosal perforation rates, myotomy success, and long-term outcomes following this hybrid (HHM) technique. Methods The myotomy was performed laparoscopically, with concomitant OGD, to scrutinize mucosal integrity and muscle fibre division simultaneously during critical myotomy steps. Alternating light sources and luminal insufflation were used to confirm myotomy completeness. All operative records were reviewed, and symptomatic improvement was measured by Eckardt score at 5 years. Results Of the 35 procedures performed, none were complicated by intraoperative perforation. Of the 20 patients available for long term follow-up, 15 (75%) had an Eckardt score of ≤ 3 at 5 or more years of follow-up, with sustained symptomatic relief up to 16 years postoperatively. Two patients experienced recurrence of moderate-to-severe symptoms, and one patient experienced recurrence of moderate symptoms. Conclusion OGD surveillance during HHM virtually eliminates the risk of mucosal injury and incomplete myotomy. This HHM technique should be considered for high-risk patients, especially those undergoing redo-Heller’s myotomy or previously treated by per-oral endoscopic myotomy (POEM), to reduce risk of mucosal injury, incomplete myotomy and imperfect fundoplication, guaranteeing long term symptomatic relief in the majority of patients.

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