Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application.

BACKGROUND: Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS: The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS: The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION: The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.

Miniature camera for enhanced visualization for single-port surgery and NOTES.

OBJECTIVE: Natural orifice translumenal endoscopic surgery (NOTES) and single-port surgery (SPS) have maximized the enhanced aesthetic profile of laparoscopic surgery. Nevertheless, these modalities also accentuate the inherent limitations of subvisibility and decreased instrument dexterity of motion. The goal of this study was to evaluate the utility of a miniature laparoscopic camera to alleviate these obstacles. MATERIALS AND METHODS: A miniature laparoscopic camera was inserted via an endoscopic working channel or embedded into laparoscopic tools. Following laparoscopic trainer studies, operations were conducted on pigs using standard laparoscopic, SPS, and NOTES approaches. Additionally, the camera was used to perform colonoscopies on mice, rats, and pigs. RESULTS: The camera enabled visualizing the dissection area behind the renal vessels during laparoscopic nephrectomy and in the Triangle of Calot in laparoscopic cholecystectomy while providing accurate and detailed visualization of the operative field. The camera was successfully passed through the working channel of a standard gastroscope and used during NOTES procedures. It was used during colonoscopy to evaluate the distal colon in pigs and allowed the diagnosis of small colonic polyps with good image quality. Additionally, it could be easily passed beyond colonic strictures created in a porcine model. Finally, its miniature size enabled performance of colonoscopies on rats serving as animal models for colonic polyps. CONCLUSIONS: The miniature laparoscopic camera provides adequate images with enhanced visibility in conventional laparoscopic, SPS, and NOTES procedures. We believe that this device or similar miniature cameras may greatly aid the future development of NOTES and SPS by enhancing the safety and ease of performing these procedures. Further development is being conducted in order to integrate this camera into standard instruments and to allow an even better image quality.