MORINO LAPAROSCOPIC HELLER MYOTOMY AND DOR FUNDOPLICATION

We are ready to show a case of a calagia,

and I think that Professor Roberto Arezzo will

present the case.

So welcome again.

This is the case of a male patient, 23 years old,

with no comorbidities reported in medical history,

that experienced mixed dysphagia for solid and liquids

from year one till now, and heartburn associated.

Endoscopy performed in July this year

showed a reduced lower esophageal sphincter relaxation,

and the manometry, a hypertonic lower esophageal sphincter

with complete relaxation in no case.

In September, sorry, this was performed in September,

and also this showed tertiary peristaltic waves

and normal upper esophageal sphincter.

Barium enema performed slightly after

shows the typical bird's beak

and nomogastric hemting.

So the indication is to perform

laparoscopic heliomyotomy

and dwarf and application.

So thank you, Alberto.

I think we can switch on the external view

as we are positioning the different trochars.

and this case will have the same position of troca as the previous one, so it's a, on

the contrary, on the opposite of the troca, it's a very thin patient, sometimes achalasia

is present, even in patients not so thin, and so here you have the xiphoid, here the

It is very narrow from the costal point of view, so the different trochers will be a

little bit squeezed one with the other, but anyway there will be four trochers more or

less in the same line, but it is a line halfway between the exiphoid and the umbilicus.

As you see, we are still using a lot of non-disposable trochers in an attempt to reduce costs.

but certainly we need a disposable trochlea for the suturing part.

So the last trochlea will be positioned at the level of the C-fold and will be used to

elevate the liver, the left rib of the liver.

It's a young patient, very robust.

Okay, so usually this procedure is performed in an antithrongolimbic position, so I ask

the abdominal part and partially the majestic one, and then to prepare for a toupee, so

So, 270 degrees anti-reflex fundoplication, so we start by exposing the Bertelli membrane,

so here the first part is to access the anterior part of the aeatus through the membrane of

Bertoldi. I'm going to enter the mediastinum and try to dissect at least

six to ten centimeters of the distal esophagus. The lesser omentum is

dissected but less than for the atalonia. This is already the esophagus, I think.

We have to go a little bit higher now. He had no previous treatments, right? No

No dilation?

Right, no previous treatment.

Okay.

That's a very good question because, again, in the 90s,

it was shown that previous treatment makes the procedure more difficult

and increases the risk of tearing the mucosa.

This was shown both for dilation and for botulinum.

It was sent to our center of physiopathology by a gastroenterologist.

then the indication was decided by the rather center of physiopathology your

question is related to the poem yeah I I was wondering if maybe a

gastroenterologist would have done something different which is the best

indication for such a patient would you accept an indication for dilation for

resistance so I think that in a young patient what was the I mean the old and

classical endoscopy meaning dilation or botulin are not anymore indicated from my

From my point of view, the indication to these two procedures are limited in patients that

are at risk of general anesthesia.

Here, there is the esophagus.

I had a moment of incertitude because I wasn't sure if this muscle was the diaphragm or already

the esophagus.

And so, very, very unfrequently, the botulinum is used as a confirmation of the diagnosis

in the sense that you have an improvement limited in time, not more than usually one

or two months, but it could be a way of confirming suspicion, but normally, manometry has no

doubt.

So, in my opinion, the indication to either dilation or botulinum are really very limited.

A discussion nowadays can be opened with the term that is the endoscopic myotomy, but the

the experience, at least in Italy, are quite limited.

And it's still a procedure under scrutiny.

But results are coming in.

And I think that this will be the competitor

of laparoscopic myotomy in the future.

So from the technical point of view,

the first part is the opening of the anterior part

of the mediastinum.

And on the opposite of reflux surgery, here it's a surgery of the esophagus, so I have

to identify the esophagus and to dissect him on a long segment, and that's what I am doing

at present.

So, I have to dissect it both into the thorax and down up to the cardias.

Yes. The other point is that I will do an anti-reflex procedure. Sorry, I was, maybe

I was, I told the toupee.

Yeah, the first time you said the door and the second time you said the toupee, yeah.

Sorry, we are doing a door procedure. Don't know why I said toupee. We did in the past

A study that I think was important, it was published in Honor of Surgery, it was a randomized

trial on 100 and I think 140 patients, comparing the DOL versus the NISN, and it showed that

both have a good control of reflux.

but with the missing we had I think 10% of recurrences of dysphagia or 15% of

recurrence of dysphagia so in line with the majority of team we have abandoned

the missing and we stick to the classical door is sufficient in this

kind of patient that has problems of motility and in which, in fact, the surgery does not

treat the pathology. The surgery simply resolves one of the problem of the pathology that is

the spasms on the lower esophageal sphincter, but in fact it remains a pathological esophagus

And that's why you have to be careful in performing a very effective fundoplication.

So now we have the lower part of the esophagus that is well dissected.

Here we have the vagus nerve.

And we are ready to start with the incision.

so the second step is identifying starting the myotomy are identifying very carefully

the two layers and the mucosa i think my tip and tricks are that you should

try to stay in the middle part and not start on the cardias but start a little bit higher

because down below the fiber the muscular fiber are much more adherent oh

I don't start very well are much more adherent with to the mucosa while as

long as you move upwards it became more easy to define the two structures there

There is a variability on the morphological point of view

because sometimes patients with achialasia have a very thick muscle,

but other times the muscle is quite thin.

So you have to be very careful as long as you identify

the right plane between mucosa and muscle.

I'm not sure.

I'm helped by two brilliant residents, Dr. Salzano,

is at the camera and see and Dr. Dana bipolar so here again there is no need

for great technology you just need to have a good bipolar and monopolar to

create the tunnel some center design a particular sensor that is protected on

on the back, similar to an instrument used

by a cardiac surgeon.

But we don't have the experience of that.

You should be careful also to identify here.

It was easy to see to identify the vagus,

because the vagus usually crosses the line of myotomy.

I think it starts to be seen down there.

So you see on my hook the longitudinal part

usually use the 3D for this procedure. It's not possible to project in 3D today, so we

shift to 2D, but it's quite helpful in this very small and precise dissection.

Okay, now this is the plane of the mucosa. You see it's protruding quite clearly, and

And once you reach the right plane, it's easy to go below and dissect with an atraumatic

force, because the mucosa is quite detached by the muscle.

And this is what, also in endoscopy, by the POEM strategy, you see very well.

I am in charge of a unit of flexible endoscopy, and Professor Arezzo, who is here, is a very

skilled flexible endoscopist and we are we are always in the ready to start for

poem then at the end we don't find suitable candidates because the results

of Heller by laparoscopy are so good that we are not hundred percent

psychologically ready to go for alternative techniques but as I told

before, the indication will grow in the future.

Maybe it will be used for failures

of myotomy, of Heller myotomy.

Very good point. Very good point. Although it's

a little bit strange from a philosophical point of

view to use a non-well-experimented

procedure for the failure of a very well-experimented procedure,

but it could be a good indication apparently there are good results it's it is probably not

as easy as one in in as a first step but I'll take him at the end of scopista perform okay

brava scusa mia perché vedo storto ma in parte legato al fatto che tu sei ecco ecco stai dritto

We are a referral center for this pathology since many years and we have a growing experience in treating failure both from our center and from other centers.

Usually the failure is related to an insufficient myotomy on the distal part, on the gastric part.

The group by Giovanni Zaninotto and the group of Padoa that are probably in the world the

most expert and with the largest series, they are reaching 1,000 cases.

Today and tomorrow there is a congress in Padoa where they have a celebration of their

1,000th myotomy.

and they have the same experience that the recurrences are usually due to

insufficient dissection distally. Proximally is quite easy you see to to

continue. I have no experience on re-operations for failures of myotomy in

laparoscopy. How is it? Is it difficult? It is quite difficult, yes.

Yes, we did overall, I think, around 10 cases, so not a huge experience, but the results were good.

Usually, I repeat, we start on the stomach, and we go on, and very often we find some fibers that are there.

In some cases, it's also connected to a non-well-shaped antireflex procedure.

Sometimes a non-well-performed door can angulate,

but in the majority, it's really a lack of myotomy.

Okay, while we join here, we can...

No, no, piano, piano.

Tira sima non tantissima.

Okay.

I think we have to go a few centimeters more.

more. Here also we use flexible endoscopy to confirm the completeness of the myotomy.

For a certain period, we did it by manometry. It's also interesting, intraoperative manometry,

you see very well the disappearance of the gradient between the two, between stomach

and esophagus, but it's quite complex to move the myotomy, not myotomy, the manometry instrument

that it's a bulky instrument and flexible endoscopy has the same and

furthermore it it's it's a check that you don't have any holes in your mucosa

try to push a little so you have to move more slowly and with this you go

in the hole here voila so we open a little bit more the mediastinum

ok ok I think we have gone sufficiently high in the mediastinum let's go

still yeah I started high because you see the vagus crosses here so I started

a little bit higher than usual I have still a good way to go down toward the

cadius I should be careful not to section the vagus it's here okay

from here on the the fibers start to have a different direction and they are

are the plan between the mucosa and the circular fiber,

it's less evident, or more than evident,

it's less easily dissectable.

This vagus nerve is quite strange,

because I don't see him crossing from one side to the other.

I don't want to cut it, but I have the impression

that it remains on the other side,

and then it crosses later.

I'm not sure I can complete my myotomy without moving the vagus on the

other side here we are on the on the cardias so we need now endoscopy I hope

they will arrive it's important to because the recurrence seems to be

be caused by this small fiber that sometimes remains here.

But I have the impression that up to here, we are complete.

It's quite a long myotomy.

.

I need a vision of the other side,

also because for the door, I need

to have the right part, or left part, in fact, of the crura

free, because I have to suture them.

So I will dissect the vagus, the amylobipolar, and that, OK?

Tira un po' di meno, più vicino.

OK.

Let's release the traction on the stomach

to see if we are at least macroscopically

on the cardius, by vicino.

Yes, more or less.

At this point, I tried to held in the joint force

at the left part of myotomy.

You see there are still some fibers.

So it's essentially to check if we have reached the Z-line,

and not only reached, but if we are at least one to two centimeters below the Z-line.

Secondary, to check the integrity of the mucosa.

No, no, no, no, no, no, no, no!

These are small muscle fibers, or sometimes they are vessels,

it's not easy to make the difference, but it's important to dissect everything.

But you, follow.

There is a little bit of fighting between the two instruments that are in the left hypochondrium

due to the really closed subcostal space.

I prefer to wait for endoscopy because I don't want to take too much risk in this part.

sometimes could be useful just to tear with the two hands in one case in one case this maneuver

in my experience provoked the opening of the mucosa I don't do it okay okay so I stop no

No, no, of course, maybe I was not, I was too strong.

No, no, it's a place where...

Sometimes now I'm not used anymore, but sometimes I measure it with a tape.

No, no, you have to do it at 6 centimeters.

Okay.

It could be interesting to measure.

Usually, it is said that you need 6 centimeters of esophagus

and 2 centimeters of cardias.

Let's see with the 6 centimeter tape what we did.

Obviously, it's changed a lot if you have a traction or not.

But anyway, we started there.

So I think that on the esophagus,

we are really quite long.

So now he's on the traction, or .

OK.

It's, I think, six to seven, even without any traction.

It depends if the cardiasis is here.

We are right.

Otherwise, we have to go one centimeter below.

I think we have to check hemostasis.

I am waiting for the endoscopist.

You said they were here, but there's Alberto, by the way.

I don't know why they didn't leave him here.

Give me a moment to bipolar.

The upper part of the myotomy is a little bit bleeding.

Okay, the endoscopy is here.

We take advantage of the presence of Alberto Arezzo to perform.

You see, maybe here there is still some muscle, I think, there.

Are you very firm like this? No? No? Like this?

Why do you always come back when I let you?

Give me the baton for a moment.

sometimes also the endoscopy helps to put in evidence small fibers because here I'm not sure

if it's okay or can we have the internal view yeah now we they are entering the mouth now so

So we are not...

Because now we are watching the trocars.

No, that's useless.

No, give him the internal image, please.

He says he's looking at the trocars.

Okay, now it's okay.

Okay.

Here, I'm not sure if these are fibers.

Maybe, yes.

Leave the internal image as well,

until he gets to the area,

because, in the meantime,

there's this liver here between the balls.

Then, in reality, the internal image

remains more and more interesting,

the internal image because here it is transparent you can see if we had alberto here in the room

okay we we albert is introducing the the endoscope if necessary you will lower our light a little

try to go up okay we see here is the light leave the okay here is the light we have to leave

the stomach. Let's go slowly. Here there is a thing that seems to tighten.

Look, you can see it well. You find it a little tight there. You see this is

interesting here. Ok, go back and take it off. Yes, yes, I have to jump a

little thing here. You see, thanks to endoscopy there was, we saw

something here it should be very careful because yeah it's quite evident but by

un po pindietro per favore alberto perché sei proprio lei si si sta indietro

perché devo farlo saltare vai decisamente ah no è la luce solo ok also the

insufflation can help a little bit okay I think it's sufficient quando vuoi

provare a riscendere okay you see he went through much more easily okay

OK, cardiasis here, tocco, OK.

So I believe that it's maybe half a centimeter

will be wise to do something more, but not too much.

But half a centimeter could be useful.

OK, semellus gonfi, facciancora mediastamico.

You don't feel any resistance, anyway.

OK.

So there is also a physical confirmation

that the endoscopist doesn't feel any resistance.

but nevertheless I prefer maybe to to go a little bit lower not too much but

and I'm not to do it I'm not at all for sale okay come on KVS to a political

area okay no no in Seattle but I'll be wrong

muskulare species you know I'm also John yes something important that we have to

to say, bipolar, on the preoperative management of this patient, many of these patients, when

there is a dilated esophagus, have a problem either of food stasis, that's classical, but

also of candidosis, and we saw that one of the causes of the risk factors for perforation

was candidosis so now since many years we are checking with endoscopy all our patients the

day before if there is a candidosis we don't perform the procedure we put the patient on

the treatment and anyway the the endoscopy the day before is useful also to clean the

food stasis remove the food stasis you see here we have a little bit of fibers

pass on corner Walter let's see a final endoscopy but now I am very satisfied

okay you see that this still is very slight there but he passes easily so I

don't want to mess up with that okay here is the cardia so we are two

centimeter below perfect okay we just desuflate and that's it okay thank you

So now we perform an anti-reflux procedure, the Novi Batufala.

Especially considering the role, the growing role of POEM,

it's important that if you operate the patient, you do an anti-reflux procedure.

In the past, not all surgeons were performing an anti-reflux procedure.

This obviously is a plus that endoscopy cannot give to the patient.

But as I told you at the beginning, it's important to have an anti-reflux procedure,

But nevertheless, we should not do a too strong one.

Otherwise, the patient will have a recurrence.

So I think that simply a door, it's feasible.

Grazie, Luca.

Usually for the door, you don't need

to dissect the short vessel on anything else.

And I think that this case is like the other.

So we can start with the first stitch.

The first one, give me the normal one, because...

Okay.

The first part is the lesser curve,

it's the, sorry, the angle of hiss that will be reinforced.

Maybe I removed...

No, okay.

Yes.

Give me a Johann down here.

No, also the one that goes in.

About 20 centimeters.

So, not too strong.

Okay.

No, no, no, no, no, that one.

Okay, so the first part is...

a suture with more or less three needles between the left part of the myotomy and the beginning

of the greater, the first part of the greater curvature. The vagus is out of the suture.

I try to use the same needle for two stitches to simplify the procedure. Sorry, but this has to

to come toward me.

OK.

respect with the Nissan.

So as we said during the previous fundoplication

that the Nissan should be short and floppy,

the partial should be longer.

So the partial applies a lower pressure on a long tract,

while the the Nissan applies a strong pressure on a short track so both door and toupee have to be

remove that small part of fat but anyway will not have any influence on the function I think

Ok, one more equal. Give me the portaghi, dice largo, forbici, one more needle on this side and then we will do the other side.

Ma tu dove guardi? Devi guardare lì, se tu guardi là. Spingi qua la tua pinza, come per toccare qua.

okay perfect okay now we suture the right and with one or two stitches I include the diaphragm

in order not to have a traction too much traction on the toe of the spleen because

We are a little bit, the camera is not easy to manage because there is a thin liver but

coming down so it's a little bit tricky to avoid the liver.

one one role of the of the door could also be to protect the anterior mucosa

at least in the distal part in case of perforation we had a few perforation

just to discuss of complication we had our serious I think it's around 300

cases we had more or less three to four not three I think intraoperative opening

maybe four I don't remember exactly and they were all in cases that had previous treatment

fortunately they were all distal so we repaired them we protect them with the with the with the

door and the post-operative course was an event for an event for in all cases we had also two

Two post-operative lesions, fistulas, that's more a problem.

One was treated conservatively, and the other one was re-operated by laparoscopy.

Unfortunately, they all were uneventful.

They appeared fortunately while the patient was still in hospital

because they stay two to three days, usually three days.

And we have a post-operative, we have the habit of performing a post-operative transit

with gastrographine, and that's one, and that is a situation in which both were diagnosed.

So I think that a post-operative transit is still advisable, and we do it usually either

on the first or on the second post-operative day, and then the patient is dismissed the

day after.

what would you do in case of persistent or or recurrent dysphagia well uh we try to understand

the cause so there could be different causes uh if it's there is a form of stenosis we usually try

dilation endoscopic dilation and in general endoscopic means and in if this doesn't work

we propose a revision but we also try to keep it conservatively many patients are not so young and

maybe they can live with a partial recurrence it depends on the severity of the recurrence so if

it's not too severe you can also try inside simply conservative management I'm I'm not sure if this

Can this can help? No, there is not much traction.

Can you imagine it together?

Well, maybe this helps a little bit.

I will give one more stitch, in fact, with the diaphragm.

We use the proline just because it's on the table.

I will give one more stitch there to reduce...

Aren't you afraid that dilation might perforate the lower part of the esophagus, where the myotomy was there?

Well, I'm talking of late recurrences.

So I'm talking of recurrences that happened some years after.

So you wouldn't do dilation in the...

In the first six months, no.

No, but anyway, we will not accept a recurrence in the first months because I think you have

to wait for an establishment of the procedure.

So if there is an early recurrence, I think surgery should be taken into consideration

because there should be something wrong in the procedure.

And the last question, maybe it's not for you, but for Professor Arezzo.

So, in case you should dilate, what kind of balloon would you use?

The standard esophageal balloons or achalasia balloons?

Did you hear, Alberto?

No, I already said, but...

The maximum size of standard balloons.

We don't use Regiflex anymore after the...

And does it work?

Well, it happens so seldom that it's really anecdotical.

But this is what, in the few cases that we had, what we did and what I know that also other centers do.

But fortunately, it is such a rare happening that there is not a clear way to behave in these things.

In old patients, we prefer to use injection of botulinum in case of recurrence, not dilation.

Yes, it's also botulinum.

I forget to mention it in the recurrence.

Good point.

Thank you.

So I think that with this last one,

one point is that this is something that we do differently

with the team of Padova, who has a great experience.

They usually leave an isogastric tube.

We don't put it because we are a little bit afraid

of passing an isogastric tube blindly

with such a myotomy but obviously in case of post-operative problem it's very useful but

fortunately we had less than 2% of severe problem so will be a 98% of none of useless nasogastric

tube so we we stop here the patient has no tube and tomorrow the order day after he will have a

transit and no no drainage right and not rain it's finished like that thank you

for this very straightforward procedure very useful thank you very much for your

chair thanks to the team Nicola and the anesthesiologist and we will come back

in two hours time with a very very low rectal cancer we hope to save the

sphincter but it's really very low fortunately in a women so we'll be at

yeti me in two hours time thank you very much see you later thank you very much