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Laparoskopische Heller-Myotomie nach erfolgloser POEM und multiplen Ballondilatationen

Besser spät als nie

Laparoscopic Heller myotomy after failed POEM and multiple balloon dilatations

Better late than never

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Zusammenfassung

Fragestellung

Trotz fehlender Langzeitergebnisse wird die perorale endoskopische Myotomie (POEM) zunehmend als vielversprechende Therapiealternative zur pneumatischen Dilatation oder laparoskopischen Myotomie bei der Achalasie propagiert. Unklar ist, welche Behandlungsmaßnahmen (Redo-POEM oder laparoskopische Myotomie) bei einem Therapieversagen der POEM unternommen werden sollten.

Fallbericht und Ergebnisse

Wir berichten über den Fall einer 37-jährigen Patientin, die – bei persistierenden Beschwerden einer Achalasie Typ I nach Versagen einer POEM – erfolgreich mittels laparoskopischer Heller-Myotomie behandelt wurde. Die Patientin unterzog sich nach manometrischer Diagnose einer Achalasie insgesamt 6 Ballondilatationen über einen Zeitraum von 5 Monaten. Bei Beschwerdepersistenz erfolgte dann eine perorale endoskopische Myotomie. Nach der endoskopischen Intervention erfolgten bei erneuter Dysphagie zwei weitere Dilatationen. Es zeigte sich weiterhin keine Besserung der Symptomatik. Die Kontrollösophagographie ergab eine ausgeprägte Erweiterung des mittleren und unteren Ösophagusdrittels bei persistierender Stenosierung des ösophagogastralen Überganges. Daraufhin wurde die Indikation zur laparoskopischen Myotomie gestellt. Intraoperativ zeigte sich eine ausgeprägte Vernarbung der Submukosa mit der Muskularis des distalen Ösophagus. Es gelang schrittweise eine 5 cm lange Kardiomyotomie ohne Mukosaverletzung. Der Eingriff wurde mit der Anlage einer anterioren Fundoplastik nach Dor komplettiert. Der postoperative Verlauf war unauffällig. Bereits unmittelbar postoperativ berichtete die Patienten über eine komplette Resolution ihrer Dysphagie.

Diskussion und Schlussfolgerung

Die publizierten Erfahrungen der POEM scheinen bisher vielversprechend bez. der Kurzzeitergebnisse zu sein. Die wenigen mittelfristigen Analysen ergeben jedoch keine wesentlichen Vorteile im Vergleich zur Heller-Myotomie. Daher ist die definitive operative Versorgung mittels Heller-Myotomie weiterhin als Goldstandard der Achalasiebehandlung zu werten. In dem von uns beschriebenen Fall erwies sich die Operation als sichere und effektive, wenngleich durch Vernarbungen sehr mühsame, Behandlungsoption auch bei POEM-Therapieversagern.

Abstract

Background

Despite the lack of long-term results, peroral endoscopic myotomy (POEM) has been increasingly propagated as a feasible alternative to pneumatic balloon dilatation (BD) and laparoscopic Heller myotomy (LHM) in patients with achalasia. After a long-term follow-up, a large percentage of patients reported recurrence of dysphagia. It is unclear which kind of procedure (redo POEM or LHM) should be utilized in these patients with failed POEM.

Case report and results

We report the case of a 37-year-old female patient with type I achalasia who was successfully treated with LHM after a failed POEM procedure. After the manometric diagnosis of type I achalasia, the patient was treated with six balloon dilatations within a period of 5 months. Because of the persistence of symptoms a POEM procedure was performed with no relief and the patient was referred for surgical treatment. An esophagography showed a pronounced widening of the middle and the distal esophagus with a persistent narrowing of the lower esophageal sphincter (LES) and because of these indications LHM was performed. The intraoperative examination revealed extensive scarring of the submucosal layer with the muscularis mucosae of the distal esophagus; nevertheless, it was possible to carry out a 5 cm long cardiomyotomy without mucosal injury. The operation was completed with a Dor fundoplication. There were no postoperative complications. After surgery the patient reported an immediate and complete relief of dysphagia.

Discussion and conclusion

The published experiences with POEM seem to show promising short-term results in terms of dysphagia relief; however, the few available mid-term analyses demonstrated no essential advantages when compared to LHM; therefore, the LHM must still be considered the gold standard procedure for definitive treatment of achalasia. According to our case report, LHM was shown to be a safe and effective although laborious treatment option due to scarring even after failed treatment by POEM.

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Authors and Affiliations

  1. Universitätsklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Paracelsus Medizinische Privatuniversität Nürnberg, Klinikum Nürnberg, Prof. Ernst-Nathan Straße 1, 90419, Nürnberg, Deutschland

    L. Giulini, A. Dubecz & H. J. Stein

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  1. L. Giulini
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Correspondence to L. Giulini.

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L. Giulini, A. Dubecz und H.J. Stein geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Giulini, L., Dubecz, A. & Stein, H.J. Laparoskopische Heller-Myotomie nach erfolgloser POEM und multiplen Ballondilatationen. Chirurg 88, 303–306 (2017). https://doi.org/10.1007/s00104-016-0332-9

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