Operative manometry and endoscopy during laparoscopic Heller myotomy. An initial experience

Area of Science:

• Gastroenterology and Surgical Innovation
• Minimally Invasive Esophageal Surgery
• Diagnostic Adjuncts in Foregut Surgery

Background:

• Laparoscopic Heller myotomy is a standard treatment for achalasia and related disorders.
• Ensuring complete division of the lower esophageal sphincter (LES) and high-pressure zone (HPZ) is crucial for surgical success.
• Traditional assessment relies on visual inspection and endoscopic insufflation, which may not fully confirm HPZ obliteration.

Purpose of the Study:

• To evaluate the utility of operative esophageal manometry as an adjunct to endoscopy.
• To determine the completeness of esophagogastric high-pressure zone (HPZ) obliteration during laparoscopic Heller myotomy.
• To quantitatively assess the adequacy of the myotomy and reduce residual LES pressure.

Main Methods:

• Twenty patients underwent laparoscopic Heller myotomy between July 1997 and October 1998.
• A 16-channel esophageal manometry catheter was placed preoperatively, crossing the LES.
• Intraoperative endoscopy identified the squamocolumnar junction; myotomy was performed and assessed visually. Operative manometry was used to detect residual HPZ, with further myotomy if needed.

Main Results:

• A persistent HPZ was identified in 50% of patients (10/20) after the initial myotomy.
• Mean LES pressure decreased significantly from preoperative values to 2 ± 3 mmHg postmyotomy (p < 0.001).
• Only 10% (2/20) of patients reported dysphagia recurrence, with one having a recurrent HPZ.

Conclusions:

• Operative esophageal manometry is a valuable adjunct to upper endoscopy in laparoscopic Heller myotomy.
• It quantitatively confirms obliteration of the nonrelaxing LES and HPZ.
• This adjunct improves the assurance of a complete myotomy and potentially reduces symptom recurrence.