Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos)
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 <.01). Endoscopic evidence of gastroesophageal reflux was identified in 52% of patients (11/21) postmyotomy; however, only 9.5% (2/11) were symptomatic, and these patients were successfully controlled with proton pump inhibitors. No severe adverse events were encountered. 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.