Heller-type cardiomyotomy using NOTES

 

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We read with interest the article by Pasricha et al. on endoscopic myotomy [1]. It is clear that esophageal myotomy could be one of the procedures easily done using natural-orifice transluminal endoscopic surgery (NOTES). Unfortunately the described technique would not enable achievement of a complete Heller-type cardiomyotomy extending into the gastric wall. While accessing the esophageal submucosal plane and incising the muscle layer is easy, performing an adequate cardiomyotomy may be difficult using this reported technique.

We have performed ex vivo and live acute experiments (not published yet) to replicate Heller myotomy in porcine models using the technique referred to as the self-approximating transluminal access technique (STAT) [2] [3]. Using STAT, a submucosal tunnel can be created and can then be extended into the gastric wall. We were able to perform a distal esophageal myotomy with adequate extension (>2cm) of the myotomy into the gastric wall.

Pigs have a closed posterior chamber called the ”caudal mediastinum”, the contents of which are the accessory lobe of the lungs and the inferior vena cava [4]. Leakage of air into this space at the time of esophageal muscle incision can lead to cardiopulmonary compromise. We wonder if the reported death was due to this.

In summary, while esophageal myotomy is possible, performance of a true Heller myotomy is more difficult. STAT enables submucosal dissection under direct visualization and true Heller-type myotomy can be achieved.

Competing interests: None

References

• 1 Pasricha P J, Hawari R, Ahmed I. et al . Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.  Endoscopy. 2007;  39 761-764
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• 2 Moyer M T, Pauli E M, Haluck R S, Mathew A. A self-approximating transluminal access technique for potential use in NOTES: an ex vivo porcine model (with video).  Gastrointest Endosc. 2006;  66 974-978
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• 3 Kalloo A. Is STAT (self approximating translumenal access technique) the first step for NOTES.  Gastrointest Endosc. 2007;  66 979-980
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• 4 Popesko P. Atlas of topographical anatomy of the domestic animals, vol 2.  Philadelphia; Saunders 1970: 114
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A. Mathew, MD

Division of Gastroenterology
Hershey Medical Center

500 University Drive

Hershey

PA 17033

USA

Fax: +1-717-5314598

Email: amathew@psu.edu