Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia

The United States human experience

Ozanan R. Meireles, Santiago Horgan, Garth R. Jacobsen, Toshio Katagiri, Abraham Mathew, Michael Sedrak, Bryan J. Sandler, Takayuki Dotai, Thomas J. Savides, Saniea F. Majid, Sheetal Nijhawan, Mark A. Talamini

Research output: Contribution to journalArticle

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Abstract

Background: From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia. Methods: Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg). Conclusions: TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

Original languageEnglish (US)
Pages (from-to)1803-1809
Number of pages7
JournalSurgical Endoscopy
Volume27
Issue number5
DOIs
StatePublished - Jan 1 2013

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Esophageal Achalasia
Pressure
Therapeutics
Manometry
Beak
Swallows
Heartburn
Positive-Pressure Respiration
Tokyo
Research Ethics Committees
Supine Position
Robotics
Barium
Deglutition
Deglutition Disorders
Gastroesophageal Reflux
Surgical Instruments
Adhesives
Immunosuppression
General Anesthesia

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Meireles, O. R., Horgan, S., Jacobsen, G. R., Katagiri, T., Mathew, A., Sedrak, M., ... Talamini, M. A. (2013). Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: The United States human experience. Surgical Endoscopy, 27(5), 1803-1809. https://doi.org/10.1007/s00464-012-2666-9
Meireles, Ozanan R. ; Horgan, Santiago ; Jacobsen, Garth R. ; Katagiri, Toshio ; Mathew, Abraham ; Sedrak, Michael ; Sandler, Bryan J. ; Dotai, Takayuki ; Savides, Thomas J. ; Majid, Saniea F. ; Nijhawan, Sheetal ; Talamini, Mark A. / Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia : The United States human experience. In: Surgical Endoscopy. 2013 ; Vol. 27, No. 5. pp. 1803-1809.
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abstract = "Background: From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia. Methods: Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg). Conclusions: TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.",
author = "Meireles, {Ozanan R.} and Santiago Horgan and Jacobsen, {Garth R.} and Toshio Katagiri and Abraham Mathew and Michael Sedrak and Sandler, {Bryan J.} and Takayuki Dotai and Savides, {Thomas J.} and Majid, {Saniea F.} and Sheetal Nijhawan and Talamini, {Mark A.}",
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Meireles, OR, Horgan, S, Jacobsen, GR, Katagiri, T, Mathew, A, Sedrak, M, Sandler, BJ, Dotai, T, Savides, TJ, Majid, SF, Nijhawan, S & Talamini, MA 2013, 'Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: The United States human experience', Surgical Endoscopy, vol. 27, no. 5, pp. 1803-1809. https://doi.org/10.1007/s00464-012-2666-9

Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia : The United States human experience. / Meireles, Ozanan R.; Horgan, Santiago; Jacobsen, Garth R.; Katagiri, Toshio; Mathew, Abraham; Sedrak, Michael; Sandler, Bryan J.; Dotai, Takayuki; Savides, Thomas J.; Majid, Saniea F.; Nijhawan, Sheetal; Talamini, Mark A.

In: Surgical Endoscopy, Vol. 27, No. 5, 01.01.2013, p. 1803-1809.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia

T2 - The United States human experience

AU - Meireles, Ozanan R.

AU - Horgan, Santiago

AU - Jacobsen, Garth R.

AU - Katagiri, Toshio

AU - Mathew, Abraham

AU - Sedrak, Michael

AU - Sandler, Bryan J.

AU - Dotai, Takayuki

AU - Savides, Thomas J.

AU - Majid, Saniea F.

AU - Nijhawan, Sheetal

AU - Talamini, Mark A.

PY - 2013/1/1

Y1 - 2013/1/1

N2 - Background: From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia. Methods: Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg). Conclusions: TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

AB - Background: From our early experience with NOTES, our group has acquired familiarity with transesophageal submucosal dissection and myotomy in swine model, which allowed us to perfect a model to perform purely endoscopic transesophageal myotomy (TEEM) for the treatment of achalasia and apply it into clinical practice. This study was designed to assess the safety, feasibility, and efficacy of TEEM in a series of patients with achalasia. Methods: Under institutional review board approval, patients were enrolled on our study, where TEEM was offered as an alternative to laparoscopic or robotic Heller myotomy. The inclusion criteria were patients with achalasia confirmed by esophageal manometry, between age 18 and 50 years, and ASA class 2 or lower. The exclusion criteria were pregnancy, prior esophageal surgery, immunosuppression, coagulopathies, and severe medical comorbidities. The procedures were performed under general anesthesia, with the patient in supine position on positive pressure ventilation. With a GIF-180 (Olympus, Tokyo, Japan) positioned at 10 cm above the GEJ, a mucosotomy was performed at the 2 o'clock position, and a submucosal space was developed caudally creating a controlled submucosal tunnel extending 2 cm distal to the GEJ. Upon completion of this tunnel the gastroesophageal lumen was inspected for mucosal integrity. The scope was then reinserted into the submucosal tunnel and using a triangle-tip knife, myotomy was performed starting at 5 cm above the GEJ and ending at 2 cm below the GEJ. During this process the circular muscle layer of the esophagus was carefully divided with preservation of the longitudinal layer. At the end of the procedure, the mucosal incision was closed longitudinally with endoscopic clips and surgical glue. Results: Five patients underwent TEEM, with no perioperative complication. All patients reported significant improvement of their dysphagia immediately after the procedure. On the first postoperative day, all barium swallows showed disappearance of the classical bird beak taper, rapid emptying of contrast into the stomach, and absence of leaks. All patients were discharged on the second postoperative day on liquid diet. Two patients reported transient heartburn, which were well controlled with medications. The average preoperative GERD-HRQL was 20, which improved to 11.3 at 7 days postoperative and 2 at 30 days postoperative. To date, three patients have already returned for their 6-month follow-up, reporting adequate swallowing and low LES pressures on esophageal manometry (their mean preoperative LES resting pressure was 36.46 mmHg and residual pressure was 43.16 mmHg, whereas the 6-month follow-up mean LES resting pressure was 10.06 mmHg and residual pressure was 0.43 mmHg). Conclusions: TEEM seems to be safe, feasible, and effective for the treatment of patients with achalasia. Long-term data are still necessary for wide-spread utilization of this novel technique.

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