Long-term Efficacy And Complications Of Peroral Endoscopic Myotomy For Patients With Achalasia

Objective Peroral endoscopic myotomy(POEM)is an excellent endoscopic treatment for achalasia.Short-term studies are ample,but long-term studies are a few.This study aimed to evaluate the long-term efficacy of POEM for patients with achalasia.Methods This was a retrospective analysis of data collected prospectively from a single center.A total of 115 patients with achalasia who underwent POEM at the First Affiliated Hospital of ZheJiang Chinese Medical University were enrolled in this study.The Eckardt score and lower esophageal sphincter pressure changes were collected before POEM,After excluding contraindications,POEM perform to treat patients with achalasia.POEM operation steps are as follows:1.Separate the esophageal mucosa layer and then establish the submucosae tunnel.2.Incise the the circular muscle.3.Close the mucosal incision.The Eckardt symptom scoring system,esophagography and esophageal manometry was repeated 1,and 12 months after POEM and annually thereafter.And to ask for gastroesophageal reflux symptoms through the Gastroesophageal Reflux Questionnaire.Gastroscopy was performed 2 months after surgery to observe the occurrence of reflux esophagitis.Results During the final follow-up,the mean Eckardt score reduced from 7.5 ± 1.9 preoperatively to 2.3 ± 1.4(P < 0.001).Treatment success was observed in 91.3% [confidence interval(CI)86.2–96.4],90.3%(CI 84.8–95.8),89.0%(CI 83.1–94.9),83.7%(CI 75.7–91.7),and 80.1%(CI 69.7–90.5)of patients after 12,24,36,48,and 60 months,respectively.A total of 97(84.3%)patients underwent esophageal manometry examination.The patients were classified as type I(16 patients,16.5%),type II(71 patients,73.2%),and type III(10 patients,10.3%)according to the Chicago classification system.The patient's pre-POEM integrated relaxation pressure(IRP)was(27.4±11.5)mmhg,and the IRP at 1 month,1 year and 2 years after POEM were(13.2±6.6)mmhg,(13.2±7.3)mmhg,(14.4 ± 6.5)mmhg,respectively.The IRP of each year after POEM was significantly lower than that before surgery(P < 0.001).A total of 16(13.9%)failures occurred.Four patients were nonresponders(failure within 3 months),eight had an early recurrence(between 3 months and 3 years),and four had a late recurrence(after 3 years).A total of 16 POEM failures three patients did not receive any interventional treatment and chose an ongoing follow-up.The remaining 13 patients received one more treatment;Pneumatic dilation(PD)was the first choice to treat the disease.Moreover,three of them experienced a symptomatic relapse after PD,and the re-POEM procedure was successful in two of three patients with complete symptom relief.Further,21(20.6%)patients had symptoms of reflux during the 2-year follow-up.Only one patient with new-onset reflux symptoms was included during the subsequent 3-year follow-up.Moreover,71(61.7%)patients underwent gastroscopy after POEM,and 13(18.3%)patients were diagnosed with reflux esophagitis.In addition a history of incomplete myotomy and interventional treatment was related to a lower chance of non-recurrence of achalasia symptoms.The logistic regression analysis was used to evaluate independent risk factors for clinical recurrence.And the myotomy length ?8 cm(OR 0.279;95% CI 0.081–0.962)and prior interventional treatments(OR 0.287;95% CI 0.083–0.994)were independently related to a lower chance of non-recurrenceConclusion In summary,the present study showed that POEM was an effective and safe endoscopic therapeutic method for patients with achalasia after a 5 years follow-up,relieving the symptoms and lowering the LES pressure.And the incidence of long-term post-POEM gastroesophageal reflux is low.