Pediatric Laparoscopic Heller Myotomy: A New Approach with Intraoperative Impedance Planimetry and Targeted Myotomy

Background: Functional luminal imaging probe (FLIP) is a diagnostic technology that assesses luminal distensibility and geometric changes as a function of pressure change within the gastrointestinal tract during endoscopy with a balloon-based catheter. This modality has been utilized in adult populations to intraoperatively monitor pressure changes during foregut operations.1–5 Pediatric achalasia is a rare motility disorder secondary to abnormal lower esophageal sphincter (LES) relaxation.6 Laparoscopic esophagomyotomy with fundoplication is the current preferred management of this disease.7,8 Typically the myotomy extends 7–9 cm (5–6 cm proximal to the gastroesophageal junction [GEJ] and 2–3 cm distal to the GEJ). Fundoplication is then performed to decrease the incidence of postoperative gastroesophageal reflux. The intraoperative use of FLIP technology allows for targeted myotomy creation. Methods: Pediatric patients (up to 19 years of age) undergoing esophagomyotomy for achalasia were included. Intraoperatively a multidisciplinary approach was utilized, including pediatric general surgery and pediatric gastroenterology. EndoFLIP device was manipulated by gastroenterologist, in real time as esophagomyotomy was performed. Real-time distensibility index (DI) and esophageal diameter were calculated to achieve a patient-specific targeted myotomy. Results: All patients had an intraoperative improvement in DI and esophageal diameter. Mean change in DI was 6.39 mm2/mmHg and mean change in esophageal diameter was 5.73 mm. Myotomy length was determined by intraoperative FLIP measurements. Myotomy length ranged from 2 to 4.5 cm. No patients underwent fundoplication. No patients reported postoperative gastroesophageal reflux on short-term follow-up. Conclusions: Intraoperative FLIP measurements provided real-time interactive feedback to guide operative therapy for achalasia. This feedback allowed for target-specific therapy and shorter myotomy creation. No competing financial interests exist. Runtime of video: 4 mins 4 secs Patient Consent Statement: “I hereby give my consent for images or other clinical information relating to my case to be reported in a medical publication. I understand that my name and initials will not be published and that efforts will be made to conceal my identity, but that anonymity cannot be guaranteed. I understand that the material may be published in a journal or other form of publication. As a result, I understand that the material may be seen by the general public. I understand the material may be used in medical books.” Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.