Trans-esophageal Cardiomyotomy Utilizing Submucosal Dissection: An Acute Porcine Procedure

Background: Previous investigators have demonstrated the ability to perform an esophageal myotomy via a natural orifice translumenal endoscopic surgery (NOTES) approach. To date, no one has performed a NOTES myotomy including both gastric and esophageal musculature.
Objective: Our objective was to perform a complete cardiomyotomy via a trans-esophageal route using the self-approximating translumenal access technique (STAT).
Methods: We performed a trans-esophageal cardiomyotomy in a 30 kg female swine. Briefly, the submucosa on the posterior esophagus was elevated by saline injection followed by needle-knife incision. A submucosal tunnel was created by blunt dissection with forceps. The endoscope was advanced to the GE junction. A myotomy was performed at the GE junction including both gastric and esophageal musculature. The endoscope was advanced through the myotomy and then was retroflexed to examine the myotomy site. The animal was euthanized and a necropsy was performed.
Results: A successful trans-esophageal cardiomyotomy (Heller) was performed in 63.5 minutes. The animal remained hemodynamically stable throughout the operation. At necropsy, a 4.5 cm cardiomyotomy was found. This extended onto the gastric wall for 2 cm. There was one unintended mucosal perforation at the myotomy site.
Conclusion: Complete trans-esophageal cardiomyotomy is possible utilizing a submucosal dissection technique; however, this was only a pilot study with an acutely sacrificed animal. Concerns remain with regard to the prevention of infection complications, as well as the management of other operative complications utilizing this method. Future studies will be needed to refine our technique and to allow this procedure to be performed safely and reliably, but we remain optimistic that trans-esophageal cardiomyotomy may be a potential NOTES application.

Session: Podium Presentation

Program Number: V008

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