Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines
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ORIGINAL SCIENTIFIC REPORT
Intraoperative Esophagogastroduodenoscopy During Heller Myotomy: Evaluating Guidelines Elizabeth H. Bruenderman1 • Neal Bhutiani1 • Robert C. G. Martin2 • Matthew P. Fox3 Victor H. van Berkel3 • Stacy B. Block1 • Farid J. Kehdy1
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Accepted: 31 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
Abstract Background National guidelines suggest routine intraoperative esophagogastroduodenoscopy (EGD) during laparoscopic Heller myotomy (LHM) to assess for mucosal perforation and myotomy adequacy, but the utility of this is unknown. This study aimed to evaluate the effect of intraoperative EGD on outcomes after LHM. Methods Patients who underwent LHM in a single center were retrospectively identified. Outcomes were compared between patients who did and did not undergo intraoperative EGD. Results Sixty-one patients were reviewed: 46 (75%) underwent intraoperative EGD and 15 (25%) did not. Mucosal perforations occurred in 2 (4%) of the EGD group and 3 (20%) of the non-EGD group (p = 0.06). All perforations, regardless of EGD use, were recognized laparoscopically. There were no postoperative leaks. Failed myotomy occurred in 5 (11%) who underwent EGD and 1 (7%) who did not (p = 0.64). Conclusions Because EGD does not appear to improve outcomes after LHM, we emphasize its selective, rather than routine, use.
Background Achalasia is a relatively rare neurodegenerative disorder in which degradation of neurons in the myenteric plexus leads to failure of relaxation of the lower esophageal sphincter (LES) and aperistalsis of the esophageal body [1]. Progressive dysphagia and its associated symptoms result.
& Farid J. Kehdy [email protected] 1
Department of Surgery, University of Louisville, 550 S. Jackson St, 2nd floor, Louisville, KY 40202, United States of America
2
Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America
3
Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, United States of America
Surgical treatment is the gold standard for achalasia and aims to relieve the obstruction at the gastroesophageal junction (GEJ) caused by failure of LES relaxation. The current favored approach is laparoscopic Heller myotomy (LHM), which entails complete division of the muscular layers of the esophagus and gastric cardia [2]. However, variations in certain technical aspects of LHM exist. Owing to the rare nature of the disease, examining the effects of these variations is difficult, and a lack of convincing evidence regarding their efficacy has prevented standardization. One such procedural variation is the use of intraoperative esophagogastroduodenoscopy (EGD). Guidelines published by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), last updated in 2011, suggest the routine use of intraoperative EGD during Heller myotomy [3]. Intraoperative EGD is recommended as a tool to assess mucosal integrity and detect areas of perforation. Its use can also ensu
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