OM plus endoscopic release of a tight fundoplication wrap to relieve recurrent dysphagia after laparoscopic hellermyotomy plus DOR fundoplication for achillesia cardia. No relevant disclosures. A 61 year old gentleman presented with recurrent symptoms of dysphagia to liquids and solids. He had a past history of laparoscopic hellermyotomy plus DOR fundoplication for type 1 achillesia cardia 6 months ago which had resulted in poor symptom response. Two subsequent sessions of pneumatic balloon dilatation had also failed. Gastroscopy revealed a dilated sigmoid esophagus with food residue. The LAS was spastic and closed and the wrap was very tight. A barium swallow confirmed the tight holdup. Since it was unclear whether the patient's symptoms were because of recurrent achillesia or because of the tight wrap, we decided to perform peroral endoscopic myotomy followed by endoscopic division or release of the fundoplication wrap. This is a cartoon showing the surgical anatomy of the DOR fundoplication. As we can see, DOR involves a partial anterior fundoplication. The fundus is sutured to the esophagus and the crest of the diaphragm. The corresponding endoscopic cross section is demonstrated in the adjoining figure. The sutures between the fundus and the diaphragmatic crest are clearly visible. During endoscopic release of the wrap, firstly the sutures between the crest and the fundus were identified and divided. Subsequently, a desialysis was performed to release the fundus from the left lobe of the liver and thereafter from the undersurface of the diaphragm. After completing standard POEM with full thickness myotomy in the lateral 3 o'clock direction, dissection was commenced deep to the muscle layer. The fundus was identified. Layer separation was achieved by injection of methylene blue stained saline. Fundus was gently dissected from the surrounding tissues. An ultraslim transnasal endoscope was passed alongside and positioned in the gastric fundus to guide the dissection. Dissection was continued between the diaphragm and the fundus. Thick adhesions were coagulated and divided using coagulation forceps. Some gastric muscle fibers were divided during the adesiolysis. In general, a subserosal plane of dissection was maintained. Gastric side myotomy was extended. Subserosal injection was repeated as required. Here we can clearly see the plane developing between the diaphragm and the fundus. The adhesions were divided to gain access to the peritoneal cavity. Here we can clearly see the plane between the diaphragmatic crest and the fundus. Dense adhesions were seen between the crest and the fundus. As dissection continued, the first pleural suture was identified. This suture was divided. Dissection was continued in the same plane to gradually separate the fundus from the diaphragm. Now the second pleural suture was identified and divided in a similar manner. As resection continued, the third crural suture was also identified and divided. Finally, the fourth suture was identified and divided to release the fundus completely from the crevice of the diaphragm. The endoscope was now advanced towards and into the peritoneal cavity through the opening created by the dissection. The left lobe of liver served as a landmark to enter the peritoneal cavity. Adhesions encountered along the way were divided. Dissection was now continued along the left border of the crevice to gradually release the fundus completely from the crevice of the diaphragm. Intraperitoneal adhesions were similarly divided using sharp dissection. It was crucial to always maintain a clean plane of dissection to avoid deep injury. Here we can see that the fundus is nearly completely separated from the diaphragmatic crust. The scope was freely passed into the peritoneal cavity to visualize the spleen and the omentum. Adhesions between the fundus and the left lobe of the liver were released. Subsequently, the fundus was released from the undersurface of the diaphragm. A thick band of omental adhesion was also carefully dissected and divided. The view of the fundus on the ultraslim endoscope showed that the wrap had opened up and that the alias was lax. The diverticulum which had formed due to the tight wrap had now opened up. Transillumination using the slim scope was performed to confirm this finding. The final dissection involved releasing the fundus further from the diaphragm and continuing the dissection in the same subsurosal plane and releasing the fundus from all its peritoneal adhesions. The final retroflexed view showed that the wrap had opened up significantly and that the esophageal mucosa was visible alongside the endoscope. After confirming hemostasis, the mucosal incision was closed using standard clips. Patient was hospitalized, clear liquids were started on day 1 and patient was discharged on soft diet on day 2. Barium swallow after the procedure demonstrated free flow of barium into the stomach across the alias. Follow-up endoscopy at one month also demonstrated that the alias was open and there was no wrap seen. Technical highlights of our case include identification and division of the wrap sutures from the diaphragmatic crest, entry into the peritoneal cavity, adhesiolysis and release of the fundus from the left liver lobe and the undersurface of the diaphragm and guiding the dissection using the ultra-slim scope placed alongside in the gastric fundus. It is difficult to clinically differentiate between recurrent achillesia and a tight wrap and both aspects should be addressed at a repeat procedure. An endoscopy and barium swallow can both be helpful in diagnosis of a tight wrap. In conclusion, OM plus endoscopic wrap release is a feasible, effective and safe procedure to treat recurrent dysphagia after laparoscopic heliomyotomy and DARF duplication.

dysphagia

achalasia

endoscopic release

fundoplication wrap

laparoscopic hellermyotomy