Transesophageal endoscopic myotomy (TEEM) for the treatment of achalasia: The United States human experience

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.