| BackgroundAchalasia, a rare esophageal motility disorder, was firstly described by Sir Thomas Willis in 1674. This disease features the esophageal body aperistalsis and impaired relaxation of the lower esophageal sphincter(LES), leading to progressive dysphagia and esophageal dilation. As this disease progresses irreversely, the main goal for treatment is to relieve clinical symptoms by lowering the pressureof lower esophageal sphincter(LES), so as to improve dysphagia. In the past decades, the most available treatments are muscle relaxants, endoscopic injection of botulinum toxin, disruption of LES by endoscopically pneumatic dilation(PD) and surgical myotomy of the distal esophageal muscular layer, known as the laparoscopic Heller’s myotomy (LHM). Among these treatments, muscle relaxant was regarded as the least effective after years of experience, and they tended to creat more medication-related complications. PD, however, gained more and more acceptance in the last few decades for patients with achalasia, while LHM was comparatively less welcomed because it was still a surgical procedure, which needed Aneasthesia and longer procedure time. What’s more, a few randomized studies showed that PD and LHM share similar long-term success rates. Therefore, even though the best treatment for achalasia is still unsure, PD is currently regarded as the first treatment for achalasia patients, especially in Europe.Although more than 90% of PD patients received excellent success rate in the short term postoperatively, symptoms recurrence tends to take place in about 20% in 2 years,30% in 5 years and almost 50% in 10 years. Debates and controversy about whether we should find a better therapeutic modality to replace PD, still exist.Regarding to the tendency of low success rate in the long-term of PD, some authors recommended LHM as the first therapeutic modality for achalasia, but be noted, LHM is an invasive surgical procedure, which also needs general anesthesia, longer hospital stay and can be risky for kinds of complications.In the last decade, as the endoscopic technologies developed, a groundbreaking endoscopic treatment came into being:peroral endoscopic myotomy(POEM). Up till now, after many studies in places around the world, the effectiveness of POEM seemed very promising. Yet no study had shown comparison of the efficacies of POEM and PD, neither whether POEM could be regarded as an alternative of PD.ObjectiveWe aimed to compare the outcomes of peroral endoscopic myotomy(POEM) and pneumatic dilation(PD) in terms of safety, feasibility, clinical statistics, manifestations and etc.MethodThis is a retrospective study, involving 102 patients with achalasia. All these patients came for treatments from July 2011 to July 2013.Before receiving any kind of treatments, all patients enderwent certain examinations to confirm Achalasia, and exclude any cases of pseudoachalasia. All these patients met the following criteria: aged more than 18 year-old; having persistent symptoms and Eckardt score of 3 plus. After the diagnosis was finally confirmed,77 of 102 patients underwent POEM and the rest 25 received PD. For patients in POEM group, they all underwent a posterior approach with an initial mucosal incision done in 5-6 o’clock position on the posterior wall of esophagus. Triangle-tip knife was used to perform the mucosal incision. After mucosal incision was done, we injected saline with indicarmine into the submucosal layer to lift up the mucosal layer. Indicarmine could help point out the direction for further submucosal dissection, avoiding perforation of either esophageal muscular or mucosal layer. Sodium hyaluronate was used instead of saline in some cases, because saline was absorbed too soon. Then we performed submucosal dissection, using saline or sodium hyaluronate with indicarmine to lift up the mucosa. A submucosal tunnel, about 7-20cm long over the LES to 3cm beneath the cardia of the stomach, was formed. After the tunnel was formed, circular muscle fibers were fully shown, and myotomy of the circular muscle fibers began from 5-8cm below the first incision site, extending into the stomach. Finishing myotomy, the opening of the cardia was much loose under gastroscopy. Finally we closed the submucosal tunnel with 10-15 endoscopic clips, depending on the length of the initial incision. For patients in PD group, we placed a balloon at the esophago-gastric junction and dilated it at a pressure of 7-15 psi, for 1 minute. After we confirmed there was no perforation or hemorrhage, then we dilated the same balloon at a higher pressure, also for another 1 minute. For all 25 patients in this PD group, we used a 30-mm balloon. After certain treatments,40mg of esomeprazole was given to every patient intravenously, every 12 hours. Prescription of esomeprazole continued even 1 month after either procedure. Patients would start with a fluid diet, and semisolid and solid diet would follow. Before be discharged from the hospital, all patients received a soluable contrast radiograph examination to confirm there is no transmural perforation. All patients were followed up for 1 year.Main Outcome MeasuresOutcome measures include symptoms relief, pre-operative and post-operative LES pressures, length of procedure, length of hospital stay, intra-operative and post-operative complications.Results102 patients were recruited in this study. The POEM group consisted of 77 patients while the PD group had 25 patients. Patients of Both groups were matched in terms of BMI, gender, age and preoperative examinations statistics. However, the post-operative statistics from these two groups are comparable. There was statistical differences in the length of procedure (60.54±24.02 vs 23.91±3.68, P=0.00) and length of hospital stay(9.49±4.45 vs 5.76±2.26, P=0.00). The incidence of intraoperative complications (18.2% vs 0%, p=0.00) is significantly higher for the POEM group. There was no difference in the 3-month post-operative Eckardt scores (1.40±1.20 vs 1.48±1.42, P=0.777) and LES pressure(14.45±6.14 vs 16.84±7.34, P=0.874) between the two groups. But in 1 year follow-up, Eckardt scores (4.23± 2.06 vs 1.18±1.08,P=0.00)and LES pressure(38.27±9.13 vs 13.42±5.56, P=0.00) are significantly higher for the PD group.ConclusionFor endoscopists, PD is comparatively easier to perform. For patients, PD also provides very satisfying outcomes, costs much less than POEM or LHM. What’s more, PD is undeniably a less risky operation. However, according to many studies around the world, the symptoms relief rate for patients, who received PD, drops as time goes on. Many of them have to come back to the hospital for further treatments, such as repeated PD, LHM or POEM. That’s to say PD fails to provide a stable symptoms relief in the long run. In our study, we found that, compared to POEM, PD was more feasible and safe, both procedures were very effective for patients with Achalasia in the short term post-operatively. However, symptoms relief seems to be more stable for the POEM patients, while for the PD patients, dysphagia tends to reoccur in the near future. |
PDF Full Text Request