Download PDF
Eur J Pediatr Surg 2012; 22(03): 217-221
DOI: 10.1055/s-0032-1308711
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Submucosal Endoscopic Myotomies for Esophageal Lengthening: A Novel Minimally Invasive Technique with Feasibility Study

James Wall
1   Department of Pediatric Surgery, Lucile Packard Children's Hospital at Stanford, Stanford, California, United States
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Silvana Perretta
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Michele Diana
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Parag Dhumane
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Jose-Ignatio Alvar Haro
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Bernard Dallemagne
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
,
Francois Becmeur
3   Department of Pediatric Surgery, University Hospital of Strasbourg, Strasbourg, France
,
Thomas Krummel
1   Department of Pediatric Surgery, Lucile Packard Children's Hospital at Stanford, Stanford, California, United States
,
Jacques Marescaux
2   Department of Digestive Surgery, IRCAD, Strasbourg, France
› Author Affiliations
Further Information

Publication History

18 December 2011

21 January 2012

Publication Date:
10 May 2012 (online)

Also available at
    Permissions and Reprints

Abstract

Background Replacement conduits carry significant morbidity in long gap esophageal atresia. Surgical myotomies can lengthen the esophagus, but have not gained widespread adoption due to long-term dilatation. The aim of this study is to assess the feasibility of an emerging minimally invasive technique of submucosal endoscopic myotomy for esophageal lengthening.

Methods Bilateral submucosal lengthening endoscopic myotomies (BSLEM) were performed in three swine. Circular esophageal muscle fibers were selectively divided in a bilateral 3 cm longitudinal pattern. Ex-vivo tensile testing was performed on the BSLEM and compared with three circular myotomies, three spiral myotomies, and three controls.

Results BSLEM was completed in all cases with one esophageal microperforation. The mean operating time was 38 minutes. Over physiologic force ranges of 0 to 100 g, the percentage esophageal elongation was significantly different among the four groups (p < 0.05). Spiral myotomy enabled the maximal lengthening among the techniques. BSLEM enabled lengthening significantly greater than controls, but less than both types of surgical myotomy.

Conclusions BSELM is feasible and allows significant esophageal lengthening. Unlike surgical myotomies, BSELM enables selective division of circular fibers to potentially preserve perfusion near the anastomosis and prevent long-term dilatation. Studies are ongoing to characterize the ideal pattern of selective endoscopic myotomy and long-term effects.

Keywords

submucosal endoscopic myotomy - esophageal atresia - natural orifice transluminal endoscopic surgery - endoscopy - minimally invasive surgery
 

  • References

  • 1 Takada Y, Kent G, Filler RM. Circular myotomy and esophageal length and safe esophageal anastomosis: an experimental study. J Pediatr Surg 1981; 16 (3) 343-348
    CrossrefPubMedSearch in Google Scholar
  • 2 Slim MS. Circular myotomy of the esophagus: clinical application in esophageal atresia. Ann Thorac Surg 1977; 23: 62-66
    CrossrefPubMedSearch in Google Scholar
  • 3 Vizas D, Ein SH, Simpson JS. The value of circular myotomy for esophageal atresia. J Pediatr Surg 1978; 13 (4) 357-359
    CrossrefPubMedSearch in Google Scholar
  • 4 Sharma AK, Wakhlu A. Simple technique for proximal pouch mobilization and circular myotomy in cases of esophageal atresia with tracheoesophageal fistula. J Pediatr Surg 1994; 29 (10) 1402-1403
    CrossrefPubMedSearch in Google Scholar
  • 5 Schwartz MZ. An improved technique for circular myotomy in long-gap esophageal atresia. J Pediatr Surg 1983; 18 (6) 833-834
    CrossrefPubMedSearch in Google Scholar
  • 6 Tannuri U, Teodoro WR, de Santana Witzel S , et al. Livaditis' circular myotomy does not decrease anastomotic leak rates and induces deleterious changes in anastomotic healing. Eur J Pediatr Surg 2003; 13 (4) 224-230
    Thieme ConnectPubMedSearch in Google Scholar
  • 7 Tannuri U, Tannuri AC, Fukutaki MF, de Oliveira MS, Muoio VM, Massaguer AA. Effects of circular myotomy on the healing of esophageal suture anastomosis: an experimental study. Rev Hosp Clin Fac Med Sao Paulo 1999; 54 (1) 9-16
    CrossrefPubMedSearch in Google Scholar
  • 8 Levine JJ, Shoshany G, Davidson M, Kimura K. Manometric variations following spiral myotomy for long-gap esophageal atresia. J Pediatr Gastroenterol Nutr 1990; 10 (3) 380-384
    CrossrefPubMedSearch in Google Scholar
  • 9 Ortega JA, Madureri V, Perez L. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc 1980; 26 (1) 8-10
    CrossrefPubMedSearch in Google Scholar
  • 10 Pasricha PJ, Hawari R, Ahmed I , et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39 (9) 761-764
    Thieme ConnectPubMedSearch in Google Scholar
  • 11 Inoue H, Minami H, Kobayashi Y , et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42 (4) 265-271
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Inoue H, Kudo SE. [Per-oral endoscopic myotomy (POEM) for 43 consecutive cases of esophageal achalasia]. Nihon Rinsho 2010; 68 (9) 1749-1752
    PubMedSearch in Google Scholar
  • 13 Perretta S, Dallemagne B, Donatelli G, Diemunsch P, Marescaux J. Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model. Gastrointest Endosc 2011; 73 (1) 111-116
    CrossrefPubMedSearch in Google Scholar
  • 14 Perretta S, Wall JK, Dallemagne B, Harrison M, Becmeur F, Marescaux J. Video: two novel endoscopic esophageal lengthening and reconstruction techniques. Surg Endosc 2011; 25 (10) 3440
    CrossrefPubMedSearch in Google Scholar
  • 15 Perretta S, Dallemagne B, Allemann P, Marescaux J. Multimedia manuscript. Heller myotomy and intraluminal fundoplication: a NOTES technique. Surg Endosc 2010; 24 (11) 2903
    CrossrefPubMedSearch in Google Scholar