The effect of esophageal myotomy and myectomy on the lower esophageal sphincter pressure profile: intraoperative computerized manometry study

Abstract

The surgical treatment of achalasia, based on Heller's myotomy is the procedure of choice to reduce the sphincterial high pressure zone, either by laparotomy or, most recently, by laparoscopy. What is the right length of the myotomy? Many authors have reported 10-15% postoperative residual dysphagia, due to the incomplete gastric myotomy and not to esophageal pouring. The aim of this study is to experimentally determine the modifications induced by Heller's myotomy and myectomy of the esophago-gastric junction on lower esophageal sphincter (LES) pressure profile, using a computerized manometric system. Myotomy of the esophageal portion of the LES (i.e. without dissection of the gastric fibers) has not modified the parameters considered, while the dissection of gastric fibers for at least 2-3 cm on the anterior gastric wall has created a significant modification of the LES pressure profile. Our observations seem to confirm and more clearly demonstrate the important role played by gastric fibers in sustaining the sphincteric HPZ. Moreover, analysis of our data, showed the need to always perform a complete myotomy. This was objectively shown during the intervention by means of intraoperative manometry, in order to significantly reduce the possibility of a dysphagic relapse, caused by inadequate treatment.

Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia

“…However, there is surprisingly little research about how far to carry the myotomy past the GEJ to the stomach (or up the esophagus for that matter). Di Martino et al [16] have shown in an animal model the need for extending the myotomy 2 to 3 cm on to the stomach. In their study, this gastric extension was much more effective in ablating the LES than was the esophageal portion of the myotomy.…”

Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model

“…The issue of a limited myotomy has been studied clinically. 11,12 However, this technique encompasses division of the longitudinal and the circular muscular bundles. Our study showed that a selective (circular bundles) and short myotomy may achieve a good functional outcome.…”

A short 4-cm oesophageal myotomy relieves the obstructive symptoms of achalasia☆

“…A number of authors have reported a gastric extension of the myotomy from 1 to 4 cm [11,12,16]. Di Martino et al have reported that extending the myotomy 2-3 cm on to the stomach is more effective in ablating the LOS and to relieve dysphagia [17]. Oelschlager extended the myotomy 3 cm on the stomach wall [18].…”