V-OG05 Robotic Hellers Myotomy

Background Achalasia is a rare condition affecting less than 1:100,000 patients. Treatment for this rare condition include balloon dilation, botox injection, endoscopic myotomy (POEMS) or surgical myotomy. Laparoscopic surgical myotomy is the “go to” approach for most surgeons; it is tried and tested, can be performed safely and quickly with a low complication rate, minimal pain and a short length of stay. Methods This video presents the technique adopted for robotic oesophageal myotomy in a patient with type II achalasia. A 4 arm technique was adopted with arm 4 on the patients left. The Davinci X system was used in this case. A Nathensen liver retractor was used to retract the liver; robotic instruments included the hook and cadiere forceps x2. Results The procedure was successfully performed; the operative time was 53 minutes, LOS was <24 hours. Check endoscopy revealed a wide open gastro-oesophageal junction and a long myotomy. The patient noted an improvement in symptoms with 24 hours and has had no significant reflux. Conclusion The enhanced magnified 3D view on the robotic platform allows better visualisation of the hiatal structures, vagal nerves and muscle fibres when performing the myotomy. Using the 4th arm to retract the lateral edge of the oesophageal muscle provides a very safe and stable platform to perform a long myotomy. I think the robotic system should be adopted as the standard approach for a hellers myotomy.

PS01.021: SHORT POEM GUIDED BY ENDOFLIP RESULTS IN LESS REFLUX RATE IN PATIENTS SUFFERING FROM ACHALASIA

Background Peroral Endoscopic Myotomy (POEM) has gained ground for achalasia tratment. Although laparoscopic Heller's-Dor (LHD) is a proven intervention, the cut of the inner muscular layer during POEM offers a goal-directed procedure. However, concerns regarding post-procedure reflux had been raised. As during POEM long myotomy is generally adviced, we decreased the length to reduce reflux after treatment. Methods 19 patients with type 1 or 2 achalasia underwent POEM guided intraoperatively by Endoflip® (Crospon Ltd., Galway, Ireland) to target the myotomy where the major point of tightness was. We aimed for an increase of compliance and distensibility of three times of the lower esophageal sphincter (LOS) via a short myotomy. We compared these patients with a historic control LHD group of 15 patients in terms of Eckardt's score, GERD-HRQL questionnaire, high-resolution manometry to check pressure of the LOS 24h pH-impedence to measure acid exposure with minimum follow-up of 9 months. Results Length of myotomy was 7 cm (6–10) for POEM and 9 cm for LHD. Median Eckard's score after POEM was 0.5 versus 2 for LHD group. Median Eckardt's score and GERD-HRQL were 0.5 vs 2 and 13 vs 15, respectively after POEM or LHD. 24h pH-monitoring revealed pathologic reflux in one patient after POEM and in 3 after LHD, with median acid % time of 0,1 vs 1,2. Data are summarized in table. Conclusion POEM is effective in achieving symptom relief in patient with achalasia. Although randomized data are not available, reflux rate after POEM with short myotomy guided by Endoflip is comparable with LHD and lower than the data of literature. Disclosure All authors have declared no conflicts of interest.