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НАБЛЮДЕНИЯ ИЗ ПРАКТИКИ / OBSERVATIONS FROM PRACTICE
© CC ® Composite authors. 2019
UDC 616.329-009.12-089.843-072.1
DOI: 10.24884/0042-4625-2019-178-3-43-46
PERORAL ENDOSCOPIC MYOTOMY WITH SIMULTANEOUS ENDOSCOPIC FUNDOPLICATION FOR THE PATIENT WITH ACHALASIA
Alexander A. Smirnov1*, Sergey F. Bagnenko1, Mariya E. Lyubchenko1,
Maya M. Kiriltseva1, Egor V. Blinov1, Nadezhda V. Konkina1, Dmitriy I. Vasilevskiy1,
Assem B. Kargabayeva2
1 Pavlov University, Russia, St. Petersburg
2 Kazakh Institute of Oncology and Radiology, Kazakhstan, Almaty
Received 19.04.19; accepted 25.04.19
To treat the patient with Achalasia and prevent the symptoms of gastroesophageal reflux the Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication was done by the current authors. After performing a myotomy the endoloop was fixated to the stomach and was attached to the muscle of the esophagus by using the endoclips. The endoloop was tightened therefore shaping the cuff. This operation has been technically feasible and no immediate or delayed complications occurred.
Keywords: achalasia, peroral endoscopic myotomy, endoscopic fundoplication, gastroesophageal reflux, dysphagia
For citation: Smirnov A. A., Bagnenko S. F., Lyubchenko M. E., Kiriltseva M. M., Blinov E. V., Konkina N. V., Vasilevskiy D. I., Kargabayeva A. B. Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication for the patient with achalasia. Grekov's Bulletin of Surgery 2019;178(3):43-46. (In Russ.). DOI: 10.24884/0042-46252019-178-3-43-46.
* Corresponding author: Alexander A. Smirnov, Pavlov University, 6-8 L'va Tolstogo street, St. Petersburg, Russia, 197022. E-mail: smirnov-1959@yandex.ru.
Пероральная эндоскопическая миотомия с одномоментной эндоскопической фундопликацией у больного с ахалазией пищевода
А. А. Смирнов1*, С. Ф. Багненко1, М. Е. Любченко1, М. М. Кирильцева1, Е. В. Блинов1, Н. В. Конкина1, Д. И. Василевский1, А. Б. Каргабаева2
1 Федеральное государственное бюджетное образовательное учреждение высшего образования «Первый Санкт-Петербургский государственный медицинский университет имени академика И. П. Павлова» Министерства здравоохранения Российской Федерации, Санкт-Петербург, Россия; 2 Казахский научно-исследовательский институт онкологии и радиологии, г. Алматы, Республика Казахстан
Поступила в редакцию 19.04.19 г.; принята к печати 25.04.19 г.
Пациентке с диагнозом «Ахалазия пищевода» была выполнена пероральная эндоскопическая миотомия с одномоментной эндоскопической фундопликацией для предотвращения желудочно-пищеводного рефлюкса. После этапа стандартной миотомии последовал этап фиксации свода желудка к области пищеводно-желудочного перехода при помощи латексной лигатуры и эндоскопических клипс. В результате была сформирована эндоскопически видимая манжета в области кардии. Послеоперационных осложнений не наблюдалось.
Ключевые слова: ахалазия, пероральная эндоскопическая миотомия, гастроэзофагеальный рефлюкс, эндоскопическая фундопликация, дисфагия
Для цитирования: Смирнов А. А., Багненко С. Ф., Любченко М. Е., Кирильцева М. М., Блинов Е. В., Конкина Н. В., Василевский Д. И., Каргабаева А. Б. Пероральная эндоскопическая миотомия с одномоментной эндоскопической фундопликацией у больного с ахалазией пищевода. Вестник хирургии имени И. И. Грекова. 2019;178(3):43-46. DOI: 10.24884/0042-4625-2019-178-3-43-46.
* Автор для связи: Александр Александрович Смирнов, ФГБОУ ВО «Первый Санкт-Петербургский государственный медицинский университет имени академика И. П. Павлова» МЗ РФ, 197022, Россия, Санкт-Петербург, ул. Льва Толстого, д. 6-8. E-mail: smirnov-1959@yandex.ru.
Introduction. Esophageal achalasia is a disease characterized by the absence of peristalsis and inability of lower esophagus sphincter to relax while swallowing. During achalasia the following symptoms occur: dysphagia, weight loss, aspiration, chest pain and regurgitation. Laparoscopic Heller's Myotomy and Balloon Dilatation have already proven to be effective for treating achalasia.
In 2008 Inoue, Japanese thoracic surgeon, and his colleagues [1] successfully performed Peroral Endoscopic Myotomy (POEM) for the first time. Currently this surgical method of treatment, performed by Inoue et al. (2008), demonstrates safeness and effectiveness in treatment the symptoms of achalasia [2, 3].
However generally in 25-30 % of cases after this operation the symptoms of reflux appeared [4].
^ А
b
Fig. 1. Contrast X-Ray images of the esophagus of the patient G., 22 years old: a — before the operation; b — after the operation (A — dilated esophagus with contrast agent; B — cardiac .sphincter constriction; C — cardiac region after the operation; D — endoclips fixing the fundus of the stomach; E — intraabdominal free gas)
While comparing Laparoscopic Heller's Myotomy and POEM the results demonstrated that after POEM the frequency of the reflux symptoms was slightly higher [4]. The possible reason for that might be the absence of fundoplication in case of POEM [5].
In February 2019 a working group with Inoue as a leading author [6] published the research which described the performance of the method of Peroral
Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication. The current authors are presenting a clinical case of application of the described method in Russia.
The patient G. of 22 y. o. has had complaints of dysphagia for 5 years. During the last year the dysphagia has become more intensified. Due to that reason, the patient had to seek medical help. In October 2018 the diagnose was established by conducting of
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Fig. 2. High-resolution esophageal manometry results of the patient G., 22 years old: A — upper esophageal sphincter (UES); B — the episode of the upper esophageal sphincter relaxation (the swallow); C — panesophageal pressurization; D — lower esophageal sphincter (LES); E — integrated relaxation pressure (IRP)
а
«Grekov's Bulletin of Surgery» • 2019 • Vol. 178 • № 3 • P. 43 [ENG]-46 [ENG]
Smirnov A. A. et al.
c d
Fig. 3. The stages of the endoscopic fundoplication:
a — moving the endoscope forward into the peritoneal cavity after making a tunnel; b — fixing an endoloop to the fundus of the stomach by using endoclips; c — fixing an endoloop to the muscle layer of the esophagus by using the endoclips; d — making a cuff after tying an endoloop (A — left lobe of the liver; B — peritoneal cavity; C — endoscopic cap; D — endoloop; E — endoclips fixing the endoloop to the fundus of the stomach; F — endoclips fixing the endoloop to the esophagus muscle; G — the formed fundoplication cuff; H — the fundus of the stomach; I — retroflexed position
of the endoscope)
contrast X-ray examination (fig. 1, a) and esophagogastroduode-noscopy. After that, the patient had undergone 5 sessions of Balloon Dilatation, which resulted in temporary positive effect.
However, in March 2019 the dysphagia symptom returned. The intensity was rated as 7/12 according to Eckardt scale, which proves the ineffectiveness of the previous treatment.
The performed High-Resolution Manometry (HRM) of the esophagus demonstrated the absence of peristalsis, panesopha-geal pressurization revealed in 100 % of swallows, the value of Integrated Relaxation Pressure (IRP) was 54 mmHg (normal value up to 15 mmHg).
Thus, according to Chicago Classification of Esophageal Motility Disorders v3.0 the patient had a type 2 achalasia (fig. 2).
The surgical treatment was offered to the patient. After receiving the consent, the Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication was performed.
In the process of surgery, the following instruments were used: the adult gastroscope EG29-i10 with distal cap (Pentax, Japan) and ultra-slim gastroscope EG16-K10 (Pentax, Japan), electro-surgical unit VIO 300D (ERBE, Germany), 30mm endoloop and ligation device (Olympus, Japan), an endoscopic q-type knife (Finemedix, Korea) and endoclips (Endostars, Russia; Olympus,
Japan). Through the endoscopes, the carbon dioxide was supplied by using an insufflator Endo Stratus EGA-501E (USA).
The operation was performed in the operating room with the help of endotracheal narcosis. Total duration of the operation was 145 min. After performing a tunnel and anterior myotomy, the orifice was made into the peritoneal cavity in the subcardiac zone of the stomach under the left lobe of the liver (fig. 3, a). Then the ligation device with the endoloop was passed to the peritoneal cavity through the tunnel in parallel with the endoscope.
In order to monitor the fixation of the loop, the ultra-slim endoscope was inserted in the stomach. This endoscope was placed in the retroflexed position for the visualization of the cardiac zone. The best place to fix the endoloop to the fundus of the stomach was found with the help of the diaphanoscopy. The endoloop was fixated to the stomach with the use of 5 endoclips (fig. 3, b). Furthermore, the endoloop was pulled up to the tunnel and was attached to the muscle of the esophagus by using 3 endoclips (fig. 3, c).
During the control of the ultra-slim endoscope, the endoloop was tightened therefore shaping the cuff (fig. 3, d). The cardiac zone was passable for the endoscope. After the haemostatic control the access to the submucosal layer of the esophagus was closed by using 5 endoclips. No immediate complications occurred.
In the early postsurgical period, the patient admitted minor pains in the epigastric region. There was no fever.
During the contrast X-ray examination on the 3rd day after the operation free gas in the peritoneal cavity remained. Cardiac zone was passable for the contrast. Evacuation was without a delay. When the examination was performed the clips fixating the cuff were evident in the cardiac zone (fig. 1, b). The patient has discharged on 4th day without any complaints. The Eckardt scale demonstrated the result of 1/12 on the 7th day after the surgery, which clearly shows the positive clinical result.
Following Inoue et al. (2019), the current authors gained a first experience of the Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundopli-cation in Russia. The clinical data that was received in the process of the operation testifies the safeness of this method. Therefore it can be recommended for the further research. There is a necessity to evaluate the long-term results by conducting HRM, pH monitoring and endoscopy. For the deeper evaluation of the reduced reflux symptoms it is valuable to conduct a series of observations.
Conclusion. In conclusion, the method of the Peroral Endoscopic Myotomy with Simultaneous Endoscopic Fundoplication proved to be perspective for the treatment of the achalasia.
Conflict of interest
The authors declare no conflict of interest. Compliance with ethical principles
The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.
REFERENCES
1. Inoue H. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271. Doi: 10.1055/s-0029-1244080.
2. Schaheen L. W., Sanchez M. V., Luketich J. D. Peroral Endoscopic Myotomy for Achalasia. Thorac. Surg. Clin. 2018;28(4):499-506. Doi: 10.1016/j.thorsurg.2018.07.005.
3. Inoue H. et al. Clinical practice guidelines for peroral endoscopic myotomy. Dig. Endosc. 2018;30(5):563-579. Doi: 10.1111/den.13239.
4. Sanaka M. R. et al. Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg. Endosc. 2018. Doi: 10.1007/s00464-018-6522-4.
5. Schlottmann F., Patti M. G. Laparoscopic Heller Myotomy versus Per Oral Endoscopic Myotomy: Evidence-Based Approach to the Treatment of Esophageal Achalasia. Am. Surg. 2018;84(4):496-500. PMID: 29712595.
6. Inoue H. et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy. 2019;51(2):161-164. Doi: 10.1055/a-0820-2731.
Author information:
Smirnov Alexander A.* (e-mail: smirnov-1959@yandex.ru), endoscopist, Candidate of Medical Sciences, Associate Professor of the Department of Hospital Surgery № 2, the Head of the Endoscopic Department of the Research Institute for Surgery and Emergency Medicine; Bagnenko Sergey F.* (e-mail: bag-nenko_spb@mail.ru), rector, Doctor of Medical Sciences, Full Professor, Academician of the Russian Academy of Sciences; Luybchenko Mariya E.* (e-mail: mashulka.87@mail.ru), endoscopist, Endoscopic Department of the Research Institute for Surgery and Emergency Medicine; Kiriltseva Maya M* (kiriltseva@ mail.ru), endoscopist, Endoscopic Department of the Research Institute for Surgery and Emergency Medicine; Blinov Egor V.* (e-mail: doctor_jaga@mail. ru), endoscopist, Endoscopic Department of the Research Institute for Surgery and Emergency Medicine; Konkina Nadezhda V.* e-mail: n_konkina@inbox. ru), resident, Endoscopic Department of the Research Institute for Surgery and Emergency Medicine; Vasilevskiy Dmitriy I.* (e-mail: vasilevsky1969@ gmail.com), surgeon, Doctor of Medical Sciences, Associate Professor of the Department of Faculty Surgery, Surgical Department of the Research Institute for Surgery and Emergency Medicine; Kargabayeva Assem B.** (e-mail: assem_doc@mail.ru ), endoscopist, Endoscopic Department; * Pavlov University, 6-8 L'va Tolstogo street, Saint-Petersburg, Russia, 197022; ** Kazakh Institute of Oncology and Radiology, 91 Abaya street, Almaty, Kazakhstan, 050022.
