Fumiaki Yano, MD, Nobuo Omura, Kazuto Tsuboi, Masato Hoshino, Se Ryung Yamamoto, Shunsuke Akimoto, Takahiro Masuda, Katsunori Nishikawa, Norio Mitsumori, Hideyuki Kashiwagi, Katsuhiko Yanaga. The Jikei University School of Medicine
Background/Aim: Although the typical complaint of patient with achalasia is dysphagia, nearly half of patients also experience chest pain, which in some cases may be intense enough to be mistaken for myocardial infarction. Further, while the main treatments for achalasia, Heller-Dor procedure (HD) and Per-oral endoscopic myotomy (POEM), have been shown to improve dysphagia, their effects on accompanying chest pain have not been satisfactory, which becomes a major issue in postoperative QOL of the patient. Here we report on the significance of the newly devised Circumference Heller myotomy (CHM) on the alleviation of chest pain.
Concept: One of the causes of chest pains in achalasia is thought to be strong contractions of the esophagus. Auerbach’s plexus extends around the entire circumference of the esophagus between the inner circular muscle layer and outer longitudinal muscle layer in a web-like fashion, which stimulates the muscular layers. As the muscle layer incision in HD and POEM is placed only longitudinally, they fail to achieve complete division of the sprawling web of nerves. Therefore if, a partial lateral incision of CHM is made for the whole circumference in addition to the conventional longitudinal esophageal muscle layer incision, the top and bottom of the Auerbach’s plexus can be fully severed, which may interrupt propagation of the esophageal contraction wave. In CHM, an incision is made in the whole circumferenceof the muscle layer, approximately 2 cm superior to the esophagogastric junction with a width of about 1 cm, after the conventional longitudinal muscle layer incision for HD. With approval from the IRB, informed consent was obtained and the treatment outcomes were investigated in 10 patients who underwent CHM (7 female, average age 49.2 years, the preoperative morphologic type was St:Sg:aSg=6:2:2, and grade of dilatation was I:II:III=1:7:2) who were observed for 3 or more months post-surgery.
Results: The average operation time was 151 minutes, the amount of blood loss was minimal in each case, and no intraoperative complications occurred. The median postoperative hospital stay was 4 days, which was equivalent to conventional HD and POEM. At 3 months after surgery, patients’ dysphagia had improved in all cases. Chest pain also improved in all cases, of whom 5 cases (50%) had complete disappearance of pain. The incidence of postoperative reflux esophagitis was 40% (4/10), which was slightly higher than HD, but were mild in all cases.
Conclusion: CHM may be effective for chest pain in patients with achalasia.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93376
Program Number: P448
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster