Esófago porcino: modelo ex vivo de entrenamiento laparoscópico para la miotomía de Heller y funduplicatura de Dor / Porcine esophagus: ex vivo laparoscopic training model for Heller's myotomy and Dor's funduplication

El dominio de procedimientos avanzados en laparoscopia es fundamental para los cirujanos, por ello el entrenamiento es imprescindible. La miotomía de Heller y funduplicatura de Dor requieren el desarrollo de habilidades y destrezas para realizar la cirugía de forma segura y eficaz, superar la curva de aprendizaje es un reto para el cirujano en formación, por lo que se propone el esófago porcino como modelo ex vivo de entrenamiento laparoscópico, con el fin de permitir desarrollar las habilidades necesarias y así llevar a cabo con éxito el procedimiento quirúrgico.Objetivo : Aplicar el esófago porcino como modelo ex vivo para el entrenamiento laparoscópico de la miotomía de Heller y funduplicatura de Dor.Métodos : Se realizó un estudio prospectivo, experimental y longitudinal, aplicado en un período de 17 semanas, en sesiones de 1 hora cada una, una sesión por semana.Resultados : Se llevaron a cabo 17 prácticas realizadas por el autor, evaluadas por cirujanos expertos, observando un aumento de la puntuación obtenida en la escala GOALS y disminución del tiempo de ejecución a medida que aumentaba el número de prácticas con una correlación altamente significativa, según la tau-B de Kendall (p=0,000).Conclusión : El modelo ex vivo permitió recrear la mayoría de los pasos quirúrgicos y demostró ser una herramienta útil y valiosa, disminuyendo el tiempo de ejecución del procedimiento y aumentando significativamente las habilidades laparoscópicas(AU)

Mastery of advanced procedures in laparoscopy is important for surgeons, therefore training is essential. Heller's myotomy and Dor's fundoplication require the development of abilities and skills to perform the surgery safely and effectively, overcoming the learning curve is a challenge for the surgeon in training, so the porcine esophagus is proposed as an ex vivo model of laparoscopic training in order to develop the necessary skills to successfully carry out the surgical procedure. Objective: To apply the porcine esophagus as an ex vivo model for laparoscopic training of Heller's myotomy and Dor's fundoplication. Methods: A prospective, experimental and longitudinal study was carried out, applied by the authors in a period of 17 weeks, in sessions of 1 hour each, one session per week. Results: 17 practices carried out by the author were carried out, evaluated by expert surgeons, observing an increase in the score obtained on the GOALS scale and a decrease in execution time as the number of practices with a high significant influence increase, according to Kendall's tau-B (p=0.000). Conclusion: The ex vivo model allowed recreating most of the surgical steps and stood out as a useful and valuable tool, decreasing the execution time of the procedure and significantly increasing laparoscopic skills(AU)

Whose patient is it? The path to multidisciplinary management of achalasia.

In the past decade, the introduction of high-resolution manometry and the classification of achalasia into subtypes has made possible to accurately diagnose the disease and predict the response to treatment for its different subtypes. However, even to date, in an era of exponential medical progress and increased insight in disease mechanisms, treatment of patients with achalasia is still rather simplistic and mostly confined to mechanical disruption of the lower esophageal sphincter by different means. In addition, there is partial consensus on what is the best form of available treatments for patients with achalasia. Herein, we provide a comprehensive outlook to a general approach to the patient with suspected achalasia by: 1) defining the modern evaluation process; 2) describing the diagnostic value of high-resolution manometry and the Chicago Classification in predicting treatment outcomes and 3) discussing the available treatment options, considering the patient conditions, alternatives available to both the surgeon and the gastroenterologist, and the burden to the health care system. It is our hope that such discussion will contribute to value-based management of achalasia through promoting a leaner clinical flow of patients at all points of care.

The Use of Rigiflex Pneumatic Balloon Dilator during Laparoscopic Heller's Myotomy in Patients with Achalasia: A Novel Technical Method and Its Surgical Outcomes.

Pneumatic balloon dilatation (BD) and laparoscopic Heller's myotomy (LHM) are usually preferred treatment options for relieving dysphagia symptoms in achalasia. The aim of the present study was to describe a new technical method for a safe and effective LHM. Endoscopic BD tube (Rigiflex 30-mm pneumatic balloon) is simultaneously insufflated and desufflated in the esophagus during LHM to assess myotomy in 50 consecutive patients. Dysphagia symptoms were determined using Eckardt's score. Three esophageal mucosal perforations occurred during surgery, which was primary repaired. The preoperative Eckardt score improved significantly from 4.54 ± 1.85 to 0.54 ± 0.73 (P < 0.001) at the first postoperative annual follow-up. The use of endoscopic BD tube during LHM is an easy and valuable method that allows to assess whether the dissection of muscular fibers in the myotomy area is appropriate or not.

Peroral endoscopic myotomy in treatment-naïve achalasia patients versus prior treatment failure cases.

BACKGROUND AND STUDY AIM: Peroral endoscopic myotomy (POEM) has emerged as an effective treatment modality for achalasia. Prior treatment may affect the outcomes of subsequent management. In this study, we aimed to compare the safety and efficacy of POEM in treatment-naïve patients vs. those with prior treatment failure (PTF). PATIENTS AND METHODS: The data of consecutive patients with achalasia who underwent POEM at a single tertiary care center from January 2013 to November 2016 were analyzed retrospectively. A comparative analysis was performed between treatment-naïve and PTF cases. Technical and clinical success, adverse events, and operative time for POEM were compared between the two groups. RESULTS: Overall, 502 patients with achalasia underwent POEM during the study period: 260 patients (51.8 %) in the treatment-naïve group and 242 patients (48.2 %) in the PTF group. The mean operative time was significantly longer in the PTF group compared with the treatment-naïve group (74.9 ±â€Š30.6 vs. 67.0 ±â€Š27.1 minutes; P  = 0.002). On multivariate analysis, type of achalasia, dilated esophagus ( > 6 cm), disease duration, prior treatment, occurrence of adverse events, and type of knife used were significant predictors of operative time. Technical success (98.1 % vs. 97.1 %; P = 0.56) and clinical success (92.4 % vs. 92.5 %; P  = 0.95) were comparable in the treatment-naïve and PTF cases, respectively. Occurrence of gas-related events and mucosotomy were similar in both groups. Elevated DeMeester score was found in 17 /53 patients (32.1 %) in the PTF group and in 11 /44 patients (25.0 %) in the treatment-naïve group (P = 0.50). CONCLUSION: POEM is safe and equally effective for treatment-naïve patients and for those in whom prior treatment has failed. POEM should be considered the treatment of choice in patients in whom prior treatment has failed.