| Objective: To research and evaluat the clinical efficacy, feasibility and security of Peroral Endoscopic Myotomy(POEM)in the treatment of achalasia,and to compare the differences in efficacy of POEM for different types of achalasia.Method: The study was retrospectively evaluated 36 cases which treated with POEM in the First Affiliated Hospital of Dalian Medical University during January 2011 to December 2013. All of the cases were diagnosed with achalasia according to the clinical symptoms and associated physical examination.To analyse the factors such as the success rate of POEM, operation condition(time of operation, postoperative hospitalization days,the length of intraoperative submucosal "tunnel" and the circular muscle incision), intraoperative complications, postoperative adverse reactions and short-term complications after POEM, and patients were followed for the comparison of the clicical symptom scores before and after the operation, postoperative gastroscopy and esophageal barium X-ray angiography examination to evaluat the effect of POEM. According to the Chicago classification,26 cases which are check esophageal manometry befor POEM are divided into two groups of type I and type II,to compare the characteristics and curative effects of POEM in different types of patients.Result:(1) 36 patients with an average age of 44.1 years old( range 17 to 64 years old)and an average disease duration of 5.5 years(range 0.3 to 26 years).All of the cases were successfully completed surgery, the success rate was 100%.The average operation time was 36.94±11.62min(range 20 to 65min);average postoperative hospitalization days was 8.78±2.27days(range 4 to 12 days);the average submucosal "tunnel" length was 12.64±0.87cm(range 11 to 15cm); average circular muscle incision length was 10.44±0.84cm(range 9 to 13 cm).(2) The clinical symptom score decreased from preoperative(7.17±1.56)points to postoperative one month(0.83±0.85)points in 36 cases, the difference was statistically significant( P<0.05). The mean follow-up period was 4.3 months(range 2 to 12 months)and the symtomy remission rate was 100%(36/36), 93.3%(28/30)and 90.9%(20/22) respectively in first,third and sixth month after the operation. Combined with postoperative gastroscope and esophageal barium meal X-ray examination, there are no relapse cases, the recurrence rate is 0.(3) 6 cases(16.7%) of 36 cases with a small amount of bleeding were all successfully treated by heat hemostatic forceps coagulation and hemostasis success; 5 cases(13.9%) of mucosa injury were all tightly sealed by titanium clip and there were no severe pneumothorax and digestive tract fistula after operation. 2 cases(5.6%) occured pneumoperitoneum and 5 cases(13.9%) appered subcutaneous emphysema or pneumomediastinum and were not a special disposal of self absorption. 9 cases(25%) of postoperative fever,all of the temperature under 38.5 centigrade,were all improvement after hypothermia therapy. According to the routine CT examination after operation, 8 cases(22.2%) of mild pneumonia were no obvious symptoms and did not appear severe pneumonia,submucosal "tunnel" infection and mediastinal infection cases after postoperative routine use of broad-spectrum antibiotics for 24 hours. 6 cases(16.7%) were aware of retrosternal discomfort, 10 cases(27.8%) felt abdominal distention or pain, 3 cases(8.3%) were chest tightness or shortness of breath, were all disappeared or relieved after treatment in tow days. According to the routine CT examination after operation,13 cases(36.1%) of mild gas related complications and 14 cases(38.9%) of a small amount of pleural effusion,all had no symptoms and no special treatment, a small amount of gas and liquid can be automatically absorbed.No cases of severe pneumothorax, pneumoperitoneum,large pleural effusion,delayed bleeding and gastrointestinal fistula and other serious complications.(4) The average operation time of 9 cases which received endoscopic treatment before POEM in 36 cases was(46.44 ± 11.04)min,it significantly longer than the average operation time(34.38 ± 10.35 min) of 27 cases which did not, the differences between two groups were statistically significant(P <0.005).But the difference of postoperative hospitalization days,the scores of postoperative Eckardt score and postoperative complication rate between the two groups were not statistically significant.(5) According to Chicago classification criteria,26 cases with preoperative esophageal manometry were divided into two groups of I type and II type, including 15 cases(57.7%) of type I and 11 cases(42.3%) of type II. The difference of the mean disease duration between two groups was statistical significance(P=0.041),type I(8.0(11.0)year) was longer than type II(4.10±1.20years) and the average operation time of type I(41.13 ± 13.52min) was significantly prolonged compared to type II(30.09 ± 9.67min)(P=0.024).The average preoperative Eckardt scores of two group cases were significantly decreased,but the efficacy of type II with an average decreased score of(7.45±1.29) was relatively better than type I with an average decreased score of(5.93±1.22)( P=0.009).(6) 36 cases were all reviewed gastroscopy and barium meal X-ray examination after one month.Gastroscopy showed the wound healed well and the lower esophageal sphincter obviously relaxation so that gastroscope could smoothly through the cardia of all cases(100%) but it could still see part of the residual titanium clip,although there were no significant improvement in esophageal morphology of 27 cases(72.2%). Postoperative barium X-ray examination showed barium could be seen through the cardia and within 1min residual barium swallow barium height were lower than preoperative values above 50% which confirmed that the treatment is effective, but there were no obvious improvement of the lower esophageal dilation compared to before in 19 cases(52.8%).Conclusion:(1) POEM as a treatment of achalasia has high success rate, fewer complications and security.(2) POEM can obviously relieve the clinical symptoms of achalasia and the short-term efficacy is significant.(3) Had received endoscopic treatment before POEM is not the contraindication of POEM,it does not significantly affect the success rate, efficacy and safety of POEM, but may increase the difficulty of the operation and prolong the operation time.(4) According to Chicago classification, the efficacy of POEM on type I and type II patients were safe and effective, but patients with type II have shorter disease duration, shorter operation time and postoperative efficacy is relatively good compared to patients with type I.(5) POEM can significantly improve the clinical symptoms and the quality of life of achalasia patients, but the postoperative changes of esophageal morphology may be no significant improvement in a short term. |
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