Long-term Efficacy Of Peroral Endoscopic Circular Myotomy And Full-thickness Myotomy For Achalasia

BackgroudAchalasia?AC?is a rare primary esophageal motility disorder characterized by disabling relax of the lower esophageal sphincter,and food stocking in the esophagus,which led to clinical symptoms like dysphagia,reflux,chest pain,weight loss and etc.Traditional treatments include medicine,endoscopic treatment?botulinum toxin injection,balloon dilatation and stent implantation?and surgical Heller myotomy incision;however,none of them is satisfactory.With the deepening of the concept of natural orifice transluminal endoscopic surgery in recent years,peroral endoscopic myotomy was first reported by Inoue et al in 2010,which has become a new method for the treatment of achalasia.Because POEM is minimally invasive,safe and effective,it has been widely applied all over the world.In order to ensure that POEM is with better efficacy and can reduce the incidence of adverse reactions,many scholars have carried out more in-depth studies based on the traditional POEM,providing more choices for the details of operation,so as to improve and innovate a variety of procedures.Traditional POEM can help build a submucosal tunnel between the mucosa and the muscularis propria,and then the esophageal circular muscle will be cut off inside the tunnel.However,with the modified peroral endoscopic full-thickness myotomy both the esophageal circular muscle and longitudinal muscle will be cut off inside the tunnel.Some scholars recommend only circular myotomy to reduce the risk of complications and other scholars prefer full-thickness myotomy to get better clinical efficacy.There are still some clinical studies which have shown no significant difference on short-term efficacy and complications between circular myotomy and full-thickness myotomy.Whether full-thickness myotomy is more conducive to the long-term relief of achalasia symptoms and whether it can increase the incidence of gastroesophageal reflux disease have not been reported.In this study,we have compared the long-term clinical efficacy and complications of achalasia of the two procedures to provide a more favorable way for treating achalasia.ObjectiveTo compare the long-term efficacy and complications of peroral endoscopic circular myotomy and full-thickness myotomy for patients with achalasia.Methods53 patients with achalasia who underwent peroral endoscopic myotomy in the First Affliated Hospital of Zhengzhou University from June 2012 to December 2014were followed-up regularly and the clinical data was retrospectively analyzed.Of the53 patients,21 patients who underwent circular myotomy belonged to the circular myotomy?CM?group,and the other 32 patients who underwent full-thickness myotomy belonged to the full-thickness myotomy?FTH?group.All the patients were followed up regularly by 28^th February,2017.The postoperative long-term symptoms and esophageal motility improvement,as well as gastroesophageal reflux complications of the two groups were compared.Results1.By 28^th February 2017,the follow-up period was 44.0 months in the circular myotomy group and 35.5 months in the full-thickness myotomy group respectively.The effective rate of the circular myotomy group and the full-thickness myotomy group was 90.5%?19/21?and 100%?32/32?,respectively.The Eckard score,the lower esophageal sphincter pressure and the 4-second integrated relaxation pressure in circular myotomy group and full-thickness myotomy group were significantly lower than those before operation?P<0.05?.2.After the operation,the Eckard scores[0?0-1.5?point VS 0?0-2.0?point],the lower esophageal sphincter pressure[?12.50±5.10?mmHg VS?13.40±3.44?mmHg]and the 4-second integrated relaxation pressure[?12.50±5.10?mmHg VS?13.18±3.38?mmHg]between circular myotomy group and full-thickness myotomy group were compared respectively,there was no significant difference?P>0.05?.3.In this study,20 cases?37.7%?had esophageal abnormal acid exposure,12?22.6%?had GERD symptoms,14?26.4%?had esophagitis and 16?30.2%?had clinically relevant GERD.The incidence of clinically relevant gastroesophageal reflux of full-thickness myotomy group was higher than that of circular myotomy group?40.6%vs 14.3%,?²=4.174,P=0.41?.ConclusionBoth peroral endoscopic circular myotomy and full-thickness myotomy are effective and the long-term efficacy of the two procedures is equivalent.However,for full-thickness myotomy,the incidence of clinically relevant gastroesophageal reflux is higher.