TRANSORAL TREATMENT OF ACHALASIA: COMBINING SUBMUCOSAL MYOTOMY WITH TRANSORAL FUNDOPLICATION

Bozzi, Rosamaria,; Roy-Shapira, Aviel; Schettino, Pietro; Cattaneo, Fabio; Pezzullo, Angelo M.; Cataneo, Domenico

UOC Chirurgia ed endoscopia digestiva AORN V.Monaldi, Napoli, Italy. / Dept . of Surgery, School of Medicine - University of Bersheeva, Bersheeva, Israel. / Dipartimento di scienze medico-chirurgiche magrassi-lanzara, chirurgia endoscopica Seconda Università degli Studi di Napoli, Napoli, Italy.

ABSTRACT
Peroral endoscopic myotomy (POEM™) is a novel approach to performing esophageal myotomy through a long submucosal tunnel and represents a feasible, safe, and effective treatment for achalasia. Recently, FDA approved a method for transoral stapled anterior fundoplication (SRS™). SRS™ Endoscopic Stapling System (Medigus, Tel Aviv, Israel) is an advanced endoscope procedure to create an effective reflux barrier, anterior fundoplication, using two or three quintuplets of standard 4.8mm titanium “B” shaped surgical staples.

OBJECTIVE
The aim of this study was to test the feasibility of combining the two procedures, thereby achieving a completely transoral myotomy with anterior fundoplication, functionally equivalent to the standard laparoscopic operation for achalasia.

DESIGN AND METHODS
The feasibility experiment was performed on a swine model at a laboratory certified according to the Israeli Animal Welfare Act. After induction of general anesthesia, a standard gastroscope was inserted into the stomach, and an overtube was slid into the mid-esophagus. A submucosal tunnel, starting about 5 cm above the GE junction and extending to 2 cm below it, was created, and the circular layer of esophageal muscle was incised using the POEM electrode. Following the myotomy, the SRS™ stapler was inserted through the overtube, and the fundus of the stomach was stapled over the myotomy, using three quintuplets of staples, in a semi-circle. At the end of the procedure, the animal was sacrificed, and the stomach with the distal esophagus were dissected out carefully, and examined macroscopically.

RESULTS
Macroscopically, the resulting fundoplication covered the distal half of the myotomized muscle, including the gastric part. No perforation was observed. The macroscopic appearance was similar to that of a standard anterior fundoplication.

CONCLUSIONS / EXPECTATIONS
It is feasible to combine the two procedures, at least in the swine model, and add a transoral reflux barrier to the submucosal myotomy. If the aganglionic segment is short (<3cm) it is possible to cover all the myotomized esophagus with the fundus, which may reduce the risk of perforation. It is probably easier to ensure that the myotomy is on the side of the esophagus covered by the fundic flap perform the stapling first, and start the myotomy between the two topmost quintuplets. Although further experiments are needed to optimize stapling location vis-a-vis the myotomy site, the combined procedure may enable the operator to achieve a result which is similar to the standard laparoscopic operation for achalasia, without violating the abodominal cavity, and without any incisions.