| Background:Achalasia(AC)is a kind of dyskinesia of lower esophageal sphincter(LES),the cause of which is still unknown.Its pathological feature lies in obstacles to relaxation of LES,making it difficult for food to reach the stomach through cardia,and later bringing a series of concerned symptoms.The main symptoms of AC include dysphagia,chest pains,acid reflux,emsis,cachexia,etc.Endoscopic balloon dilation,botox injections,esophageal stents implanation,and surgical treatment are major therapies for AC.Endoscopic balloon dilation proves to be valid with short treatment time,efficacy decreasing over time.However,some patients may need multiple dilation,at a risk of complications like perforation.Botox injections are easy to be performed with mild drug resistance and few complications,whose disadvantage is short period of validity and repeated operation.Temporary esophageal stents implanation,mostly taken as a transitional treatment,is likely to have such complications as stent migration or detachment,and have high risk of acid reflux after operation.Surgical treatment is effective,but may have significant complications.Since firstly reported by Inoue in 2010,peroral endoscopic myotomy(POEM)has been accepted by increasing clinicians due to its amazing therapeutic effect,which is equal to the surgical treatment and has little trauma.However,there are a few reports about POEM's long-term effect on AC.Objective:To explore short-term effects,complications and therapeutic evaluation of POEM on Achalasia.Methods:A total of 44 AC patients,who received POEM from June 2012 to May 2016 were retrospectively enrolled.Their age ranges from 11 to 82 years,46.9±16.1 on average.Course of disease varies from one months to 40 years,averagely 99.5 ± 102.8 months.Operating procedure of POEM is as follows:(1)slice open esophageal mucosal layer,establishing tunnel opening;(2)isolate submucosal layer,setting up tunnel under the mucous membrance;(3)slice open circular muscle by means of the gastroscope,fully through all layers of the muscle near cardia;(4)clip the incision of mucosal layer with endoscopic clips.The changes in Eckardt Grade,esophageal diameter on both chest CT and X-ray imaging,body weight before and after operation were analyzed.Results:The time of POEM procedures varies from 45 to 311min,(118.9±65.7)min on average.The length of tunnel under the mucous membrance was 12.9±1.1 cm,and the length of myotomy was 9.6±2.4 cm.Random sample visit to these 44 patients for 1-39(9.3±9.2)months shows such symptoms as dysphagia,pain in the back of sternum and acid reflux have been relieved.Compared with 6.6±2.0 before operation,postoperative Eckardt Grade had declined to 1.2±1.1 in one month,1.1±1,1 in three months and 1.2±1.2 in six months.Thirty two cases have had Eckardt Grade decreased from 6.5±2.0 before operation to 1.3±1.2 postoperation in one month,1.3±1.1 in three months,1.4±1.3 in six months and 1.2±1.1 in one year.Fourteen cases have had reduced from 6.2±2.4 before operation to 0.8±0.9 postoperation in one month,0.9±0.9 in three and six months,0.9±1.0 in one and two years.Body weight has increased from 53.2±10.9 kg before operation to 58.3±11.7 kg postoperation.Ten cases show esophageal diameter on chest CT reduced from 41.5±14.9 mm before operation to 25.7±8.5 mm postoperation.Compared with those before operation,ten cases have smaller esophageal diameter with X-ray barium meal exam by(29.3±16.8)%.One case of esophageal fistula and mediastinal emphysema occurred postoperative.The patient got better by itself without any special treatment.Among 27 cases of fever(61.4%),seven cases reached 38.5?and above,two cases were discovered pulmonary infection and bilateral pleural effusion another five cases returned normal in four days.Twenty cases got body temperature ranging from 37.2 to 38.5?,one of which was found full of subphrenic free air,and later got improved after treatment on intensive anti-infection and continuous decompressing on intestines and stomach.Four out of 19 cases received chest CT,one diagnosed as double pneumonia and turned under control with treatment like anti-infection.Ninteen cases returned normal within four days.No case died during perioperative period and follow-up period.Conclusion:POEM has proved to be safe and effective aiming at achalasia.Effect of surgery is measured by subjective indicator like Eckardt Grade and quality of life assessment,along with objective indicator like esophageal X-ray barium imaging,endoscopy,and esophagus pressure detection,etc.Decline scope of Eckardt Grade combined with objective indicator can predict effect of surgery objectively. |
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