1. Update on Achalasia – Techniques and Outcomes William O. Richards MD, FACS Professor and Chair Department of Surgery and the Division of Gastrointestinal/Oncologic Surgery University of South Alabama College of Medicine University of South Alabama Medical Center Mobile, Alabama

2. Esophageal Motility - Achalasia

3. Postop LES Pressure > 18mmHg=bad result

4. Postop LES Pressure Change < 18 mmHg = bad result

5. Transesophageal Endoscopic Myotomy (TEEM) Pig study EMR mid esophagus with snare Submucosal tunnel After reaching the GE junction the LES was divided using triangular knife and electrocautery Gazala et al Surg Endosc 26: 2012

6. Transesophageal Endoscopic Myotomy (TEEM) Results in 3 animals Mediastinal sepsis Esophageal ulcer Pneumothorax Gazala et al Surg Endosc 26: 2012

7. Transesophageal Endoscopic Myotomy (TEEM) Potential pitfallAction taken Mucosal IschemiaSlim endoscope 10 cm tunnel pneumothoraxCircular muscle dissection, CO2, Dedicated instruments, CXR, Deflation of mediastinum Vagus nerve injuryOrientation of myotomy in 10 o’clock position Gazala et al Surg Endosc 26: 2012

8. Transesophageal Endoscopic Myotomy (TEEM) Results with modifications to procedure Gazala et al Surg Endosc 26: 2012

9. Transesophageal Endoscopic Myotomy (TEEM) Revised procedure Effective in opening GE junction No mucosal ulcer Gazala et al Surg Endosc 26: 2012

10. Transesophageal Endoscopic Myotomy (TEEM) Conclusions Technically feasible but not ready for prime time Recommend – Strict protocols – Dedicated instruments Hook knife Balloon dissection of tunnel Gazala et al Surg Endosc 26: 2012

11. Transesophageal Endoscopic Myotomy (TEEM) 7 patients Operative time 69-124 minutes Circular layers divided leaving longitudinal layer intact Start 5 cm above GEJ and extending 2 cm on stomach Mucosotomy site closed with endoscopic clips Meireles et al presented at SAGES March 2011

12. Transesophageal Endoscopic Myotomy (TEEM) 7 patients Operative time 69-124 minutes 1 patient developed pneumoperitoneum 1 patient with subcutaneous emphysema Dischared home on POD #2 taking liquid diet Resolution of dysphagia in all Meireles et al presented at SAGES March 2011

13. Transesophageal Endoscopic Myotomy (TEEM) Results in 3 patients Meireles et al presented at SAGES March 2011

14. Transesophageal Endoscopic Myotomy (TEEM) Results in 3 patients Meireles et al presented at SAGES March 2011 2 patients developed GERD and were placed on PPI

15. Transesophageal Endoscopic Myotomy (TEEM) Conclusions “TEEM provides benefits of a complete surgical myotomy, while being a totally endoscopic procedure and therefore associated with very quick post-procedural recovery, minimal pain and the possibly of evolving to an outpatient procedure.” “Hence TEEM has the potential to become a routine practice in the near future as the treatment of choice.” Meireles et al presented at SAGES March 2011

16. Per Oral Endoscopic Myotomy POEM Procedure

17. Esophageal Acid exposure Symptoms do not correlate with acid exposure Reduced LES pressure Reduced esophageal clearance increases esophageal acid exposure

18. No Correlation Between Acid Exposure and Symptoms Postoperative GSRS GERD Score % total reflux 082 0 4 8 12 16 Postoperative GSRS GERD Score R 2 =0.05

19. Mechanisms of GERD

20. Typical post-Heller Upright Reflux

21. Mechanisms of GERD

22. Typical post-Heller Recumbent reflux

23. Heller with Dor Fundoplication

24. Completed Dor Fundoplication

25. Video of Heller + Dor

26. Incidence of Pathologic GER Heller + Dor procedure was associated with a significant reduction in the risk of pathologic GER (relative risk: 0.11; 95% confidence interval 0.02-0.59; P=0.01) P=0.005 47.6 % 9.1 %

27. Distal Esophageal Acid Exposure Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*). P=0.001

28. Postoperative LES pressure mmHg Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*).

29. Postoperative Dysphagia Scores Data are shown as median (horizontal line), interquartile range (box), and 5th to 95th percentile (vertical line). Outliers are marked with the asterisk (*).

30. Conclusions Dor fundoplication significantly reduces postop GERD after Heller myotomy Relief of dysphagia is similar in both techniques Heller + Dor fundoplication is preferred procedure for treatment of Achalasia