The Development Of Endoscopic Treatment Of Esophageal Achalasia

BackgroundEsophageal Achalasia is a primary esophageal disorder termed as lack of peristalsis of esophageal body and also relax of the lower sphincter. Due to the unknown origin, the treatment is mainly palliative, aim to facilitating the evacuation of the esophagus and ease the suffering symptoms. We try to discuss the improvement of endoscopic treatment of Esophageal Achalasia from three aspects including the review of diagnosis and treatments of Esophageal Achalasia, peroral endoscopic myotomy,POEM to treat Esophageal Achalasia,management of complications when therapeutic endoscopy. This article not only provides the proper choice of treatments for reference,but also makes sense in the study of other endocopy for gastroesophageal diseases.Part1the review of diagnosis and treatments of Esophageal AchalasiaIn this part,we review the clinical symptoms, diagnosis criteria, pathogenesis of Achalasia in detail,and also the treatments,incluing drug treatments, Botulin toxin injection,Ballon Dilation, cardiac stent insertion, esophageal Heller myotomy,especially study the parameters of Heller myotomy for POEM.Part2the new attempt of peroral endoscopic myotomy,POEM to treat Esophageal AchalasiaObjective:To assess the efficacy and feasibility of POEM in treatment of Esophageal Achalasia.Methods:From October19th2011to Apirl24th2012,4patients diagnosed as Esophageal Achalasia accepted POEM. All patients’s clinical manifestinations and timed barium swallow were compared before and after operation.The main procedure of POEM are:1Endoscopic resection of the esophageal mucosa to explore the submucosa;2 Dissection of the mucosa to create a submucosal "tunnel";3endscopic resection of lower esophageal sphicters;4Closure of mucosal entry with hemostatic clips.Result:The mean maximum diameter of the esophageal body decrease by14.01mm according to the time barium swallow, all the patient have a certain relief of dysphagia.One patient had a mucous leak as complication,but after nonoperative treatment, he recoverd to have normal diet with good operation outcome.One patient developed pneumothorax and subcutaneous emphysema, who recover soon after5days closed drainage of the thorax.Conclusion:POEM can reduce the dysphagia symptoms of Achalasia in the short term, but observations of the long term outcome and delayed complications are still needed, the optimum circular musles cutting expanse is under discussion.POEM is an application of Submucosal Tunneling Technique, which creates a tunnel between the mucosa and muscular layer,and through which we can carry out endoscopic treatments. It can be apply in (1)treatment of lesion within mucosa,such as the extensive or even circular early esophageal cancer;(2)treatment of muscular layer, POEM and STER(Submucosal tunneling endoscopic resection)for example;(3)the diagonosis and treatment of the diseases out of the gastroesophageal cavity,such as removal of lymph node and excison of tumor,so it is with NOTES (natural orifice translumenal endoscopic surgery,et al.It separates the site of mucosa insicion and the site of serosa perforation,and can be easily closed after the sugery, so it is named as "mucosal safety valve"Part3management of complications when therapeutic endoscopyThe occurrence of complications such as bleeding and perforations is increasing accompaning with the improvement and innovation of the therapeutic endoscopy.The management become very important. Management of perforations provide technoligcal support for the closure of the openings of NOTES.In this part,we introduce a successful method in treating with a patient developing a leak of mucosa after operation,and review other methods dealing with perforation,including closure with hemostatic clips, closure with membraned stent, biogum conglutination, combined closure of endoscopic ligation and hemostatic clips, clamping after greater omentum aspiration,suture with special instruments,close with Cardiac Occluder just like septal occluder,et al.The creation of these methods, largely reduces the harms of the perforation,give mental support to endoscopist and relieve the anxiousness of patients.