BACKGROUND:
Laparoscopic Heller Myotomy (LHM) plus fundoplication is a standard treatment method for achalasia. A tight fundoplication wrap is a potential contributing factor for recurrent or residual dysphagia following myotomy and difficult to differentiate from a true achalasia recurrence. This video demonstrates per oral endoscopic myotomy (POEM) followed by endoscopic wrap release in a patient with recurrent dysphagia following LHM plus Dor fundoplication

METHODS:
A 61year old gentleman who underwent LHM with Dor Fundoplicaton for Achalasia six months prior followed by twice Pneumatic balloon dilatation presented with recurrent symptoms of dysphagia to liquids and solids. Barium swallow-contrast hold up and slow transit across LES seen. Gastroscopy-dilated tortuous esophagus with food residue seen. POEM plus Endoscopic release of Dor fundoplication wrap was performed using third space endoscopy principles. Gastro esophageal (GE) Junction identified at 52cms. Mucosal incision was done laterally at 38cms using TT knife. Submucosal dissection was carried out using TT knife in antegrade direction. Myotomy was commenced at 40cms, and full thickness myotomy was continued till 2cms beyond GE junction. After myotomy, fundic wrap was identified deep to the myotomy and fundus was dissected from the adhesions. Four sutures were identified between fundus and crura and were dissected. Trans nasal endoscope was introduced into fundus to guide the dissection and to perform transillumination as required. Simultaneous dissection on the right and left of diaphragmatic crus was performed Adhesiolysis was done between left lobe of liver and stomach, and between stomach and undersurface of diaphragm. Care was taken to prevent full thickness injury to the gastric wall and liver. Scope was passed into peritoneum, retroflexed and dissection was carried out and fundus was released. Hemostasis was confirmed, endoscope was withdrawn from the tunnel and mucosal incision closed.
RESULTS:
Patient was kept fasting overnight and gastrograffin study was done -Free flow of contrast into the stomach was seen. Patient was started on liquid diet -day 1, soft diet day 2 and discharged on day 2 . Follow up gastroscopy and barium swallow done after 1month. Gastroscopy-Scope could be passed easily across GE junction without resistance. On retroflexion there was no obvious wrap seen and LES was lax. Barium swallow - Free flow of barium was seen with minimal hold up.

CONCLUSION:
Endoscopic release of tight fundoplication wrap is a feasible, safe and effective procedure to treat recurrent dysphagia post LHM plus Dor fundoplication.

Arun Arora Pagadapelli

Appearances