Clinical Research And Risk Factors Analysis Of Difficult Peroral Endoscopic Myotomy

Objective:Although most of the peroral endoscopic myotomy(POEM)can be successfully completed,a small number of complex patients will still encounter various problems during POEM.This part of POEM is called difficult POEM,which mainly includes a prolonged procedure time,occurrence of major intraoperative adverse events or aborted POEM procedures;By analyzing the incidence and risk factors of difficult POEM,we systematically carried out clinical research on difficult POEM.Methods:132 patients with achalasia who underwent POEM in the General Hospital of the Western Theater of the Chinese people’s Liberation Army from May 2015 to may 2021 were studied retrospectively.The relevant factors,preoperative examination data and intraoperative conditions of the patients were analyzed.The clinical outcome was the incidence of difficult POEM,including operation time≥90min,operation suspension and the occurrence of major adverse events.The independent risk factors of difficult POEM were screened by univariate analysis and multivariate logistic regression.Results:Among 132 patients,29(21.97%)had difficult POEM;Operation time≥90 min in 23 cases(17.42%);Major complications occurred in 8 cases(6.06%);128 cases(96.97%)were operated successfully,and 4 cases(3.03%)were aborted due to severe submucosal fibrosis and tunnel failure.Univariate analysis showed that age≥50 years old(X~2=12.129,P<0.001),History of previous treatment(X~2=5.465,P=0.019),Henderson grade 3(H=11.156,P=0.004),sigmoid esophagus(X~2=11.884,P=0.001),SMF2/3(X~2=19.359,P<0.001)and mucosal edema grade 1 or 2(X~2=8.075,P=0.004)were associated with the occurrence of difficult POEM;Multivariate analysis showed that age≥50 years old(OR:3.681;95%CI:1.491～9.650;P=0.008)and previous history of balloon dilatation or surgery(OR:4.979;95%CI:1.359～18.246;P=0.015);SMF-2/3(OR:5.205;95%CI:1.973～13.731;P=0.001)was associated with the occurrence of difficult POEM.Conclusion:1.POEM is a relatively safe operation,with low incidence of major complications and few cases which were suspended.2.Age≥50 years old,previous balloon dilatation or operation history and SMF-2/3 grade are independent predictors of difficult POEM.For these patients,it is recommended to be cautious and operated by experienced endoscopists.3.SMF-2/3 can effectively predict difficult POEM and is also an independent risk factor for prolonged operation time,thus the grading of mucosal fibrosis is an effective means of grading.4.When taking the operation time as the evaluation index of learning curve,it is feasible to take 15 cases as the learning curve of POEM.