Multimedia manuscript. Heller myotomy and intraluminal fundoplication: a NOTES technique.

Area of Science:

• Gastroenterology
• Minimally Invasive Surgery
• Endoscopy

Background:

• Achalasia treatment often involves surgical myotomy, but can lead to reflux in up to 30% of patients.
• A transoral incisionless approach offers a potential alternative to traditional surgery for achalasia.
• This study explores a stepwise transoral incisionless method for Heller myotomy and fundoplication.

Purpose of the Study:

• To evaluate the feasibility and effectiveness of a stepwise transoral incisionless approach for esophageal Heller myotomy and fundoplication.
• To assess the impact of the procedure on lower esophageal sphincter (LES) pressure and esophagogastric junction (EGJ) distensibility.

Main Methods:

• A two-step transoral incisionless procedure was performed in a porcine model.
• Step 1: Esophageal Heller myotomy using endoscopic techniques and submucosal tunnel creation.
• Step 2: Transoral incisionless fundoplication using the EsophyX™ device, performed 4 weeks post-myotomy.

Main Results:

• Both Heller myotomy and fundoplication were successfully completed without esophageal mucosa injury.
• Postoperative manometry showed a significant reduction in mean LES pressure (from 22.2 to 10 mmHg).
• Endoscopic evaluation with EndoFLIP® demonstrated increased EGJ distensibility (minimal diameter from 6 to 15 mm; cross-sectional area from 28 to 177 mm²).

Conclusions:

• A stepwise transoral incisionless approach for Heller myotomy and fundoplication is feasible and effective in a porcine model.
• The functional lumen imaging probe (EndoFLIP®) provides valuable insights into EGJ dynamics beyond manometry.
• This technique may offer a less invasive option for achalasia management, potentially reducing reflux complications.