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cross the thin remaining longitudinal muscle layer to enter the
peritoneal cavity below the phrenoesophageal ligament when
making the myotomy. Patients can get signiﬁcant subcutaneous
emphysema for the same reason above the phrenoesophageal
ligament. Because CO2 is used, this will dissipate in the early
postoperative phase.
The patient is admitted postoperatively and undergoes an
esophagram the following morning, where leak and passage of
contrast through the LES is assessed. A liquid diet is started
after the esophagram is cleared and the patient is discharged.
The patient undergoes another esophagram 1 week later to assess
for a healed mucosotomy, and the diet is advanced as tolerated.
The patient follows up 3 to 4 weeks postoperatively and at 6 to
12 months. Eckardt scores are taken at both follow-up visits.
The laparoscopic Heller myotomy procedure
The patient is taken to the operating room and placed in
supine position with a footboard in place. Laparoscopic access
is obtained with a liver retractor elevating the left lobe of the
liver. In the primary surgery group, the gastrohepatic ligament
is incised to expose the lesser sac. The caudate lobe is identiﬁed and the gastrohepatic ligament is taken down following
the edge of the caudate lobe until the right crus is seen. The
anterior phrenoesophageal ligament is incised to access the mediastinum. The anterior vagus nerve is identiﬁed and preserved.
The mediastinal dissection is done only to the extent of the
projected myotomy length. Upper endoscopy is then performed
to identify the high pressure zone, outlining the exact location
of the hypertensive LES.
A 6 to 8 cm myotomy is completed, with the extent of the
myotomy starting 2 cm distal to the LES on the stomach and
extending up the esophagus. Using the harmonic scalpel, the
muscle ﬁbers are incised down to the mucosa of the stomach.
The submucosal plane is then accessed and the myotomy is created measuring 6 cm cephalad. If a mucosal injury is made, a 4-0
vicryl suture is used in a ﬁgure-of-eight fashion to approximate
the edges of the mucosa. Once the myotomy is complete, an
upper endoscopy is done to perform a leak test and verify the
patency of the LES. Short gastric vessels are then taken down
to mobilize the fundus. Anterior fundoplications are created
using 0-Ethibond sutures, tacking the greater curvature of the
fundus to the hiatus and laying the fundus over the myotomy,
creating an approximate 90 degree fundoplication. Three total
sutures are used to create the fundoplication by suturing the
greater curvature of the fundus to the hiatus. No drains are used.
The capnoperitoneum is released, and the liver retractor and all
trocars are removed. Skin closure is done with 4-0 monocryl
sutures and then dermabond.
The patient is admitted postoperatively for an esophagram to
assess for leak and passage of contrast into the stomach. A liquid
diet is started after the esophagram is cleared and the patient is
discharged. The patient follows up 3 to 4 weeks postoperatively
and 6 to 12 months postoperatively. Eckardt scores are taken
at both follow-up visits.
In redo surgery, the procedure is similar except that the enterolysis is performed with the harmonic scalpel, blunt dissection,
October 2017

and sharp dissection to return the stomach to its anatomical position and to evaluate the myotomy. Extension of the myotomy is
performed if it appears inadequate. Upper endoscopy is used to
guide the dissection and further myotomy. Postoperative management is the same as with the primary LHM cohort.
RESULTS
A total of 12 patients underwent POEM (4 men and
8 women) and 11 patients underwent LHM (6 men and
5 women). The demographic and clinical characteristics of the
two groups are compared in Table 1; no diﬀerences were statistically signiﬁcant. Patients' mean age was similar between the
groups: 52 in the POEM group and 53 in the LHM group.
Those in the LHM group had a higher mean body mass index
than those in the POEM group (28.8 vs 25.7 kg/m2). In the
LHM group, 8 patients (73%) had type 1 achalasia, 2 patients
(18%) had type 2 achalasia, and 1 patient (9%) had type 3
achalasia; in the POEM group, 10 patients (83%) had type 1
achalasia, 1 (8%) had type 2 achalasia, and 1 (8%) had esophagogastric junction outﬂow obstruction. The mean procedure
time was shorter in the POEM group, at 136 minutes compared
with 154 minutes in the LHM group. The postoperative length
of stay was a mean of 1.6 days for the POEM group and 2.0 days
for the LHM group.
As shown in Table 2, mucosal injury occurred in 1 patient
in the POEM group and 3 patients in the LHM group. For
the POEM mucosal injury, a hemoclip was placed when it was

Table 1. Demographic and clinical characteristics of patients
undergoing POEM vs LHM for management of achalasia
Variable
Women

POEM (N = 12) LHM (N = 11) P value
8 (67%)

5 (46%)

0.41*

Age (years), mean ± SD

52.0 ± 16.9

52.7 ± 12.4

0.91†

BMI (kg/m2), mean ± SD

25.7 ± 4.0

28.8 ± 5.2

0.12†

Preop LES basal, mean ± SD

33.6 ± 18.8

28.8 ± 14.0

0.52†

Preop LES residual, mean
± SD

23.3 ± 14.9

15.6 ± 9.8

0.09†

Patients with aperistalsis
preop

9 (75.0%)

9 (81.8%)

0.98*

Type 1

N/A

Type 2

N/A

Type 3

N/A

EGJOO

N/A

Procedure length (min), mean
± SD

136 ± 64

154 ± 37

0.43†

Hospital LOS (days), mean
± SD

1.6 ± 1.2

2.0 ± 1.9

0.53†

Achalasia type

P value based on *Fisher's exact test; †Student t test.
BMI indicates body mass index; EGJOO, esophagogastric junction outflow obstruction;
LES, lower esophageal sphincter; LHM, laparoscopic Heller myotomy; LOS, length of
stay; POEM, per-oral endoscopic myotomy.

Laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017