Oral endoscopic myotomy in the treatment of neuromuscular diseases of the esophagus

Among the methods of treatment of neuromuscular diseases of the esophagus, we can distinguish conservative (antispasmodic drugs), endoscopic (augmentation, balloon dilation, botulinum toxin injection, prosthetics with biodegradable stents) for achalasia, cardia, surgical (open esophageal cardiomyotomy, thoracic cardiomyotomy, laparoscopic cardiomyotomy). The ineffectiveness of conservative methods in the treatment of these diseases has been proven to date. The use of the above-described endoscopic methods is limited by the significant cost and the need for periodic repetition of the procedure. The effectiveness of surgical treatment is quite high, however, such interventions often have a long period of recovery and rehabilitation and are not effective in diffuse esophagospasm. 

The development of operative endoscopy, including transluminal surgery, made it possible to develop various methods of endoscopic interventions, including oral endoscopic myotomy, on an experimental model and to introduce them into clinical practice.

The essence of the operation is to dissect the circular muscle fibers of the lower third of the esophagus for 5-7 cm, the lower esophageal sphincter and 2-3 cm of the cardiac part of the stomach. Access to the submucosal space is carried out through a mucosal incision 3-4 cm proximal to the upper level of the planned myotomy. 
The intervention is performed in the patient's back position under general anesthesia in a ventilator. To reduce the possible negative consequences (mediastinal emphysema, tense pneumoperitoneum, pneumothorax, and air embolism), the operation is performed using carbon dioxide.